Hypertension in renal failure

Attending rounds: a patient with drug-resistant hypertension

Drug-resistant hypertension is present in about one in eight patients with high BP. It can be a frustrating and expensive condition to pursue from an office-based perspective. In this review, utilizing the American Heart Association scientific statement on drug-resistant hypertension as a guide, a case of drug-resistant hypertension is presented and walked through exactly as encountered by the author. Woven into the discussion is a combination of insights from the literature on this topic, blended with the experience of the author. This is not intended as an exhaustive review of each step in the evaluation and management process but, rather, as an overview incorporating a few carefully chosen references and, hopefully, a logical and useful approach to a common clinical challenge.

Evaluation and treatment of chronic renal failure

Chronic renal failure (CRF) is the irreversible deterioration of renal function that gradually progresses to end stage renal disease (ESRD). The chief causes of CRF include obstructive uropathy, primary glomerular diseases, reflux nephropathy and hypoplastic or dysplastic kidneys. Progressive hyperperfusion and hyperfiltration causes increasing glomerular injury and further renal damage. Symptoms of CRF are usually seen when GFR is between 10-25% of normal. Children with severe CRF often suffer from failure to thrive, growth retardation, acidosis, anemia and renal osteodystrophy. Management of CRF aims at retarding progression of renal damage and treatment of complications related to renal dysfunction. Measures suggested to retard progression include protein restriction, strict control of hypertension, use of angiotensin converting enzyme inhibitors and control of hyperlipidemia. Appropriate amounts of protein and calories are recommended to prevent growth failure. Nutritional supplements are often required. The availability of recombinant erythropoietin, calcitriol and human growth hormone has significantly improved the management of these patients. Once ESRD supervenes, renal replacement therapy in the form of chronic peritoneal or hemodialysis and transplantation is necessary.