Dear Dr Falkinburg
Sorry I could not respond to your questions earlier. You have been maxed out. I will now try and answer as many of your questions as possible:
1. I am from South Africa
2. The generic names for the three medicines you do not recognise are:
a)Zanidip - Lercanidipine
b)Bilocor - Bisoprolol
c)Physiotens - Moxonidine
3.My husband ia 64
4.He is not diabetic
5.It was noted only three or four years ago that he had CKD and it has been presumed that is was caused by uncontrolled hypertension. As I said, they have been considering a biopsy but are hesitant due to the fact that he lost his left kidney after a rugby injury many many years ago.
6.He had an ultrasound and the report was as follows:
Right kidney is normal in size - 11.9 (I have heard that when there is only one kidney it increases in size to compensate for the missing one and so I have presumed that perhaps his remaining kidney did previously increase in size and has now perhaps got smaller with the worsening kidney function)Increased in echogenicity which could be due to renal failure, nephritis. Minimal cortical thinning noted, measuring 0.9. Is this bad?
7.We are never given copies of the pathology reports here. The doctors only advise when results are not normal. We have only been advised of high blood creatinine and potassium plus low haemoglobin. Recently the creatinine has ranged from 207 (2.34mg/dl) to 270 (3.05mg/dl) and the potassium as I said went from 6 to 7.8 where he was hospitalased for treatment and he was taken off the medications, Rampiril and Spiractalone. Subsequently his potassium went back to normal but then two days later it had increased to 5.8 and another two days later to 6.4. The next blood trest was normal with no intervention, It is currently normal and his creatinine is 270.
I hope you can help me with my questions. Another query I did not put to you was the question of whether I should consider him to be at stage 3b or stage 4 CKD considering that much of the last year his GFR levels have been 30 or below although there were two readings of +-40 in the middle of that time.(Not sure how this was possible?) Also, do you think he will inevitably progress to stage 5. His hypertension remains a constant problem and the doctors seems unable to control it. With the recent addition of Moxonidine his BP goes up and down from high to normal and back to high again. Many thanks for your help. Rose
Good morning, Rose,
First, please let me apologize to you for the delay in my response. Somehow, I managed to delete your original question and the copy on the "all experts" site did not extend to include your original questions. Therefore, I'm going to give you my email address so you can communicate with me without dealing with my being "maxed out".
Email address: firstname.lastname@example.org
Feel free to follow up with me at the above address and, if you would, please resend your original correspondence.
The staging of chronic kidney failure by the National kidney Foundation is meant to be only a rough guide in assessing the degree or extent of chronic kidney failure (CKF). The stages can be simplistically viewed as Stage 1, essential normal; Stage 5 is ready for dialysis and stages 2,3 and 4 are simply mild, moderate and severe. Their utility ends there as the treatment becomes specific to the nuances of the particular case. For example, your husbands case has to be focused upon good control of his blood pressure, both to slow or prevent the progression of his kidney failure and to protect his heart and brain from the deleterious effects of severe hypertension. I rarely use the staging designations.
His medications are still not in my data base, I think, because they are old generics and probably produced in Africa. However, I believe that lercanidipine is a dihydropyridine calcium channel blocker, used to treat severe hypertension (also heart failure). Bisoprolol is a beta blocker and moxonodine is probably a drug called minoxidil in the USA and is the most powerful blood pressure medication known. It is rarely used in the USA because, although it is extremely effective, it has many side effects. It also, occasionally, can accelerate to he progression of kidney failure. It is a last resort for pressures that cannot be controlled any other way. It will protect the heart and the brain from the ravages of hypertension. I notice that he is not on a diuretic. He should be because the hypertension associated with kidney failure is often volume dependent and a diuretic and a low salt diet constitute the cornerstone of blood pressure treatment in these patients. I would recommend that he be placed on furosamide 40 to 160 mg a day as well as a low salt diet (3-4 grams per day). Because of problem with hyperkalemia (high potassium) I would also suggest a low potassium diet (2 grams per day).
He has been on aldactone in the past and it was discontinued because of his hyperkalemia. This is very appropriate, but unfortunate, because it often can facilitate the control of blood pressure. So, in his case, the dietary modification will have to suffice. Also, ramipril is a medication (an ACE inhibitor) that has been shown to slow the progression of kidney failure. He was on this medication but its discontinuance was required because his creatinine rose above 2 mg% and now is 3 mg% (209 mm/l). He has a significant contraindication to all of the medications that we use for the preservation of kidney function as well as the one that helps control severe hypertension. Therefore, dietary manipulation is very important in his management. So, in addition, I would, also, suggest that the protein content of his diet be reduced to 40 grams per day. Protein restriction in kidney failure has been shown to slow the progression of the disease in nearly all cases. His diet, then, would be described as a 40 gram protein, 3-4 gram sodium and 2 gram potassium diet. I believe that he really needs this.
We usually recommend a kidney biopsy if we think that there might be some other disease present that is treatable, and that the treatment has sufficient side effects that we would not wish to subject the patient to it otherwise. In your husband's case, a co-existent glomerulonephritis would be essentially the only such disease. I would examine his urinary sediment and look for evidence of a "nephritic" process. If I saw none (that is likely), then I would NOT do the biopsy. Although your husband's kidney size is within the normal range, it really is not, because he has a solitary kidney. Normally, his kidney size should be around 13 cm in length. A size of 11 is small for him. The cortical thinning represents kidney tissue that has been lost to disease and is not good. Therefore, in all likelihood, his disease is chronic in nature and no specific treatment is going to alter the course. My opinion is decidedly UNENTHUSIASTIC for a kidney biopsy.
A narrowing of the artery supplying his kidney with blood can cause hypertension, aggravate preexistent hypertension and can cause and/or aggravate kidney failure. It is here, in my opinion, that the best chance resides to find something to both improve his hypertension and improve his kidney function. I would strongly recommend that he undergo Doppler renal artery imaging to be sure that the artery is widely patent. If there is any question, I would do a CT angiogram with contrast (we don't usually do this because it has some risk) to be sure. If he has a significant narrowing of that artery it should be fixed.
Rose, this is all extremely complicated. It is as complicated as it gets! Therefore, please feel free to communicate any further questions that you may have to my email.
I hope I have been helpful.