Case: Your new patient is Mrs. Jones, a 65-year old African American woman who h
ID: 3517818 • Letter: C
Question
Case: Your new patient is Mrs. Jones, a 65-year old African American woman who hasn't seen a primary care provider in many years. She is obese, taking no medications and feels fine but has come in because her children thought she should have a checkup. During the checkup you note that she has swollen feet and ankles. Her blood pressure is 168/112 mmHg, and readings taken at home with an automated monitor confirm these values. Her urinalysis is positive for albumin. She is scheduled for a renal clearance test, which comes back showing a GFR of 30 ml/min. Over the next two months this GFR is confirmed. You prescribe a diuretic and an ACE (angiotensinconverting enzyme) inhibitor and schedule her to meet with a dietician to help her limit the sodium and protein in her diet.
Diagnose her and answer the following questions.
a. Does this patient have any risk factors for hypertension? What is the BP above which someone is considered to have hypertension? Does she have hypertension?
b. What does her GFR tell you about her kidney function?
c. Explain the connection between her blood pressure and her kidney function. Will controlling her BP help her kidneys?
d. Explain why this patient has edema, and albumin in her urine.
e. Explain how the diuretic and ACE inhibitor will affect her kidney function to control her edema and blood pressure
Explanation / Answer
Answer a. In given case obesity is a risk factor for hypertension. Obesity causes the stiffness of the blood vessels and thus increasing blood pressure. The diastolic blood pressure above 140 mmHg is considered as the case of hypertension and blood pressure in the range of 120-139 is considered as prehypertension. The systolic blood pressure above 90 mmHg is considered as hypertension. Since the patient given in the case has blood pressure 160/112 mmHg so this patient comes under the category of hypertension.
Answer b. GFR is glomerular filtration rate. It is defined as the rate by which the kidney filter the fluid flowing to the kidney. The normal value of GFR is, 125 ml per minute. In case of any disease or deformity in the kidney the GFR is reduced as it is vivid in the given case scenario.
Answer c. Blood pressure is closely related to the kidney function. Blood pressure is determined by how the kidney maintained and fluid balance by secretion and reabsorption of the fluid in the body. If kidney retains more fluid the blood pressure is increased and if fluid loss is more the blood pressure is reduced. If BP is controlled, then this will help kidney to work less. Thus the workload on the kidney is reduced. It will maintain the well being of kidney function and prevent it from deterioration.
Answer d. Due to increased blood pressure, the plasma protein like albumin and globulin is filtered from the glomerulus. This causes release of albumin protein in the urine. As the consequence of the albumin loss in the urine, the plasma concentration is reduced that is plasma becomes hypotonic. This hypotonicity of the body fluid results in swelling and edema of body starting from feet and ankle.
Answer e. Edema and increased blood pressure is due to the hypotonicity of the body fluids. Our aim is to increase concentration of the body fluid either by increasing water loss or by increasing plasma proteins. Diuretics causes release of more water from the body by acting on the kidney by secretion of the more water. Thus the concentration of the body fluids become normal and edema and blood pressure is controlled. ACE inhibitor causes the inhibition of the conversion of angiotensin I into angiotensin II. Thus the vasoconstriction caused by angiotensin II is inhibited. This results in more fluid reaching the kidney that is increased GFR and more fluid loss from the body. This results in decreased edema and blood pressure.