You are on page 1of 6

Case Study 1: Secondary Hypertension

A 47-year-old female patient underwent a 24-day treatment program at The Center for Chronic Disorders for
treatment of hypertension due to kidney damage. The patient's problem began at age 17 when she was admitted
to the hospital for obstruction of the right kidney. She underwent surgery to relieve the obstruction; however,
the kidney had been damaged. She was told this damage would be permanent and, as a result, she could expect
to have elevated blood pressures for the rest of her life. For the following thirty years the patient had widely
varying blood pressures, with most pressures being significantly elevated.

Blood pressure readings were obtained during the two months preceding treatment at The Center and averaged
146/97. (Blood pressure is considered high when the upper number, the systolic pressure, is 140 or higher, or
when the lower number, the diastolic pressure, is 90 or higher.) During the 24-day Chronic Disorders Program,
the patient received a multimodality in-residence program, including the use of the newly introduced Vedic
Sound Therapy which the patient felt played a central role in her subsequent improvement.

Following in-residence treatment, the patient was placed on a home program including dietary
recommendations and specific herbal preparations. Within a few days of leaving The Center, the patient's blood
pressure dropped significantly and became normal.

Two months later, they continued within the normal range, averaging 129/85. The patient reported that she had
not had blood pressures this low since adolescence. In addition, an initial 24-hour creatinine clearance test (a
sensitive measure of overall kidney function) was obtained at the beginning of the treatment program and
repeated several weeks after its completion. The initial creatinine clearance was moderately diminished (67
ml/minute, with normal being between 80-120 ml/minute), indicating diminished overall kidney functioning.
The follow-up was in the normal range at 85 ml/minute.

Case Study 2: Diabetes Type II, Hypertension, and Depression

A 55-year-old gentleman entered The Center for Chronic Disorders on November 5, 1997 for a 21-day course
of treatment for hypertension, Type II diabetes (non-insulin dependent) and depression. On admission to the
program, he was taking medication for control of all three disorders. Following is a brief synopsis with respect
to each disorder:

a. Hypertension: Prior to starting medication in 1995, his blood pressure had been elevated (170/106). A few
months prior to starting the Chronic Disorders Program (CDP), he had attempted to come off the medication on
his own, but his blood pressure became elevated within one week (160/90) and the medication had to be
resumed. On entering the CDP his blood pressure on medication was normal; however, he was experiencing
side-effects from the medication, including depression and fatigue. After beginning the CDP his blood pressure
medicine was stopped, but his blood pressure remained normal. On completing the 21-day program he was
placed on a home regimen which included some of the treatments used during the CDP. Five months following
the CDP, his blood pressure continued to be normal (average 121/79) without medication.

b. Diabetes Type II: On admission his blood sugars were poorly controlled, with daily fasting blood sugars
averaging 212 during the month prior to his entry into the program (the ideal value for a diabetic is less than
120). During the 21-day CDP, his diabetes medicine was tapered to about one-half the admission dose. Despite
this decrease in medicine, his fasting blood sugars dropped to an average of 118.7 over the final 12 days of
treatment, a drop of 93 points from admission. His weight decreased from 147 on admission to 144 at discharge.
Five months following the CDP, his hemoglobin A1C (a test of long-range blood sugar control) was 7.4
(excellent control), compared to 8.4 just prior to admission. His medication dose remained half the pre-
admission dose.
c. Depression: His mood brightened considerably during the first week of treatment; he stopped the
antidepressant medicine of his own volition mid-way through the program. Five months later, he continued off
antidepressant medication without any depression or anxiety symptoms.

Case Study 3: Hypertension

A 45-year-old executive had uncontrolled hypertension, despite medications. He was obese and fatigued and
was therefore unable to exercise; he also had an uncontrollable appetite. The patient attended an in-residence
chronic disorder program. His weight dropped, and he was able to begin exercise; he also stopped both alcohol
and tobacco. Six months following this program, he continued to have normal blood pressure on herbal
preparations but no medications and was able to eat as much salt as he liked.

Hypertension is a disease and with all diseases, you should worry about it.
Not only should you worry about it, but you have to fully understand the
disease and become familiar with the treatments available for it.

Hypertension is a serious disease. It is one that can kill you. That is if you
don’t get treatment for it. You can go to your doctor and have him or her
diagnose you with high blood pressure. While high blood pressure can’t be
diagnosed in just one doctor visit, it is important that you schedule regular
visits with your doctor so he can measure pressure that runs in your blood.
After several visits, your doctor can plot and read the readings that were
taken.

After the doctor has determined that you do indeed have


this disease, the doctor will prescribe medications that control pressure in your blood. These high blood pressure
cures work good and have worked good for dozens of years. There is no denying that.

However with all doctor prescribed medications, there are side effects. Some of these side effects can be in fact
worse than the disease itself. So, should you worry? Yes because even if you do get treatment for your disease
from your doctor, odds is you are left open to succumb to the side effects of the medications. Some of these side
effects are annoying and some are deadly.

Such side effects include constant urination. These are typical of diuretic medications. They work by removing
excess salt in your blood system through your urine. Imagine having to go to the bathroom every 30 minutes or
more frequently just to keep your blood pressure under control? It will be definitely hard for you to go to
concerts, the movies, out to dinner. It is an annoying and embarrassing side effect of diuretics.

Other serious side effects include death! Yes you can die from these side effects. You can have a bad allergic
reaction to the medicine. Also, these medications can affect your liver. If you liver goes out on you. Your body
wont be be able to filter out the deadly toxins your body expels. The toxins will simply continue circulating in
your body and after you accumulate enough toxins in your body, you can die from self poisoning.

These are indeed serious side effects from hypertension. You must keep pressure in your blood under control.
However, doctors give you these medications that pose harm to you because they are subsidized by the
pharmaceutical companies. That is why if you ask them if there are other alternatives for natual high blood
pressure medicine to the drugs you are taking, they will simply indicate to other drugs. Not very optional right?
Case Study On Person With Hypertension
Hypertension symptoms are actually rarely noticed. This is very fearsomeupsetting if someone live with
hypertension. Hypertension of high blood pressure is a every day growing danger.

Risks With Hypertension And Obesity


Among hypertensive heart disease patient, risk factors such myocardial infarction, angina pectoris, diabetes, left
venticular hypertrophy and valvular heart disease are conditions which can lead to heart failure.

Signs Of High Blood Pressure In Women


Hypertension is known as the silent killer for good reason. Some 50 million Americans have high blood
pressure and one-third of those don’t even know it.

Only Have Higher Blood pressure


A new study in a American Heart Association journal shows that it likely that patients whose blood pressure
readings are higher in the doctor’s office have what the authors call “masked hypertension.”
Finding Out the Finest Hypertension Medication
Are you looking for an effective hypertension medication? First that you need to do is to check a Combipres.
This is a common medication.

10 Signs And Symptoms Of Hypertension


Even those who take the medicine, just take the anti-hypertensive shortly. Studies have shown that 90% of
patients with hypertension do not show respect for their drugs.

Case Study: A 57-Year-Old Man With Type 2


Diabetes, Hypertension, and Microalbuminuria
Jeffrey A. Luerding, MD

Presentation
R.C. is a 57-year-old man with type 2 diabetes first diagnosed 2 years ago. Other medical problems include
obesity and hypothyroidism. He has a history of heavy alcohol use but quit drinking alcohol 2 years ago. He
presents now for routine follow-up and is noted to have a blood pressure of 168/100 mmHg. He is
asymptomatic.

Physical exam reveals a height of 5 feet, 8 inches, weight of 243 lb, blood pressure of 160/100 mmHg, and a
regular pulse of 84 beats/min. There is no retinopathy or thyromegaly. There is no clinical evidence of
congestive heart failure or peripheral vascular disease.

Laboratory evaluation reveals trace protein on urinalysis, blood urea nitrogen of 14 mg/dl, serum creatinine of
1.2 mg/dl, random serum glucose of 169 mg/dl, normal electrolytes, and normal thyroid-stimulating hormone
levels. A 24-h urine collection reveals a urinary albumin excretion rate of 250 mg/day.

Questions

1. Does this patient have renal disease?


2. Should his blood pressure be treated?
3. What treatment strategy should be used?

Commentary
Diabetic nephropathy is a clinical syndrome characterized by albuminuria, hypertension, and progressive renal
insufficiency. Diabetic nephropathy is the most common cause of end-stage renal disease (ESRD) in Western
countries, accounting for ~35% of all new ESRD cases in the United States. The life expectancy of patients with
diabetic ESRD is <50% at 3 years, despite improvements in dialysis and renal transplantation.

Early detection and treatment of albuminuria is essential in diabetes. A normal urinary albumin excretion rate
(UAER) ranges from 0 to 30 mg/day. Overt albuminuria or macroalbuminuria is defined as a UAER >300
mg/day. Many studies have shown that a UAER >30 mg/day is abnormal and can be used to predict the
development of overt albuminuria or diabetic nephropathy and both microvascular and macrovascular disease.
As a result, the term "microalbuminuria" was coined to refer to a UAER of 30–299 mg/day.

Many organizations, including the American Diabetes Association, recommend regular screening for
microalbuminuria. Type 1 diabetic patients should be screened 5 years after diagnosis of diabetes and after
puberty. People with type 2 diabetes should be screened from the time of diagnosis, since many type 2 diabetic
patients have had undiagnosed disease for some time. If the initial screening is negative, then annual screenings
are indicated.

Traditional urinary dipsticks are insensitive at detecting albuminuria <300 mg/day. Spot urine samples may be
assayed for microalbuminuria and creatinine and a ratio >30 µg/mg or mg/g is abnormal. Newer methods, such
as Micral-Test II test strips (Boehringer Mannheim, Mannheim, Germany), permit reliable semiquantitative
determination of microalbuminuria and can be used in the office for dipstick screening of diabetic patients.

Transient elevations in urinary albumin excretion may be associated with marked hyperglycemia, acute febrile
illness, exercise, hypertension, heart failure, and urinary tract infection. If the initial test is elevated, these and
other potential causes of renal disease should be considered and ruled out. Because there is also marked day-to-
day variability in urinary albumin excretion, a positive test should be confirmed on a subsequent occasion
before designating a patient as having persistent microalbuminuria.

Patients identified with persistent microalbuminuria should be aggressively treated both with respect to
glycemic and blood pressure control. Patients are considered to be hypertensive if their blood pressure is
>140/90 mmHg. The goal for the management of hypertensive diabetic patients is to keep the blood pressure
<130/85 mmHg.

The treatment of choice for hypertensive diabetic patients with or without microalbuminuria remains
angiotensin-converting enzyme (ACE) inhibitors. Only captopril (Capoten) is approved for the treatment of
diabetic nephropathy, but all ACE inhibitors appear to be effective. Fosinopril (Monopril) has a dual route of
elimination and therefore may have an advantage over other ACE inhibitors, particularly when used for patients
with renal insufficiency or failure.

Once started, renoprotective therapy should be continued indefinitely. ACE inhibitors have been shown to
prevent or slow the progression from microalbuminuria to overt nephropathy. Studies have also shown that the
renoprotective effects of ACE inhibitors go beyond those expected from blood pressure reduction by itself.
Additionally, the renoprotective effects apply to both normotensive and hypertensive patients with
microalbuminuria. Therefore, the indication for ACE inhibition can be persistent microalbuminuria, regardless
of blood pressure. Discontinuing therapy will result in a recurrence of microalbuminuria.

In addition to aggressively managing blood pressure, attempts need to be made toward lifestyle modifications.
These include meticulous control of blood glucose, seeking counseling to stop smoking, maintaining optimal
body weight, following an appropriate diet, and exercising regularly.

Clinical Pearls

1. Screen diabetic patients for microalbuminuria.


2. Recognize hypertension in diabetic patients with a blood pressure >140/90 mmHg.
3. ACE inhibition is the preferred treatment of microalbuminuria and/or hypertension.
4. Counsel diabetic patients on lifestyle modifications, including blood glucose control, weight control,
smoking cessation, diet, and exercise

SUGGESTED READINGS

de Cotret PR: Relationships among diabetes, microalbuminuria, and ACE inhibition. J Cardiovasc Pharmacol
32 (Suppl 2):S9-17, 1998.
Mogensen CE, Viberti GC, Peheim E, Kutter D, Hasslacher C, Hofmann W, Renner R, Bojestig M, Poulsen PL,
Scott G, Thoma J, Kuefer J, Nilsson B, Gambke B, Mueller P, Steinbill J, Williamowski K-D: Mutli-center
evaluation of the Micral-Test II Test Strip, an immunologic rapid test for the detection of microalbuminuria.
Diabetes Care 20:1642-46, 1997.

Mogensen CE: Preventing end-stage renal disease. Diabet Med 15 (Suppl 4):S51-56, 1998.

Parving HH: Benefits and cost of antihypertensive treatment in incipient and overt diabetic nephropathy. J
Hyperten 16 (Suppl 1):S99-101, 1998.

Luno J, Garcia de Vinuesa S, Gomez-Campdera F, Lorenzo I, Valderrabano F: Effects of antihypertensive


therapy on progression of diabetic nephropathy. Kidney Int 54 (Suppl 68):S112-19, 1998.

Jeffrey A. Luerding, MD, is a family physician in private practice in Kansas City, Mo.

Return to Issue Contents

Copyright © 2000American Diabetes Association


Updated 7/00
For ADA Related Issues contact CustomerService@diabetes.org

For Technical Issues contact webmaster@diabetes.org