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A study on hypertension among chronic kidney disease patients admitted in the nephrology department of GGH, Kurnool.

INTRODUCTION: Chronic kidney disease (CKD) is emerging as a major public health problem in developed as well as developing countries. The prevalence of chronic kidney disease in the population is a considerable social and economic problem worldwide, and one that is increasing (1). One of the reasons for this is said to be the rapidly increasing incidence of hypertension. Hypertension has been reported to occur in 85% to 95% of patients with CKD (stages 3-5). The relationship between hypertension and CKD is cyclic in nature. Uncontrolled hypertension is a risk factor for developing CKD, is associated with a more rapid progression of CKD, and is the second leading cause of ESRD. It has been recently estimated that the age-adjusted incidence rate of ESRD in India to be 229 per million population (pmp). (2) Meanwhile, progressive renal disease can exacerbate uncontrolled hypertension due to volume expansion and increased systemic vascular resistance. (3) Studies have also shown that better blood pressure control slows progression of chronic kidney disease. Lowering blood pressure will reduce the risk of heart disease, which for most patients with chronic kidney disease, is more of an immediate threat than end stage renal disease. (4) Alcohol and smoking are said to play key role in the management of hypertension and blood pressure can often be lowered without medication merely by reducing consumption of alcohol. The present study is undertaken to understand the role of hypertension and its management in CKD patients admitted in the nephrology department of Kurnool Medical College.

OBJECTIVES:

1. To study the association between hypertension and Chronic Kidney Disease.

2. To study the other known risk factors and complications associated with hypertension among CKD patients.

MATERIALS AND METHODS:

Study Design: Cross sectional descriptive study.

Study Period: June to November 2012,

Study Area: The Department of Nephrology, Government General Hospital, Kurnool.

Study Subjects: The chronic kidney disease patients admitted in the Nephrology ward from June to November 2012 were included in the study and were interviewed with a Pre-designed semi structured questionnaire. Three readings of blood pressure were obtained in the sitting position after at least 5 minutes of quite rest. A subject was considered hypertensive if one had systolic blood pressure (SBP) of [greater than or equal to] 140 mmHg or diastolic blood pressure (DBP) of [greater than or equal to] 90 mmHg (the average of two measures that were taken in the seated position), or if he or she was using antihypertensive medication. The diagnosis and classification of HTN was done according to the JNC-VII report on Hypertension. (4)

Statistical Analysis: Chi-square test and percentages.

Data analyzed by EPIINFO software version 7.

RESULTS: Total study subjects were 153 in number. Their age ranged from 13 to 75yrs and the Mean age was 47.96 [+ or -] 11.14 years. Hypertension was present in 126(82.35%) of the patients with CKD. Age had a significant association with the presence of hypertension (p<0.05) whereas gender, education, economic status had no difference (Table 1). 90.48% of the hypertensive patients were in stage 4 CKD when compared to 74.07% of the patients with normal blood pressure which was statistically significant (p<0.05) (Table 2). Of all the patients with hypertension 69(54.7%) were having hypertension before the diagnosis of CKD, 40(31.75) were simultaneously diagnosed along with CKD and 13.49% of the patients developed hypertension after the diagnosis of CKD (Figure 1) Family history of CKD was reported by 23.02% of the hypertensive patients whereas none of the patients with normal blood pressure had family history of Chronic Kidney Disease (p<0.05) (Table 3). Presence of Hypertension had an increased risk (15.87% vs. none, P<0.05) for Heart disease. (Table 4) Only 4.35% of the patients with blood pressure under control had heart disease when compared to 29.82% of the patients with inadequate control (p<0.05) (Table 5) Among 105 male CKD pts 88.24% of the smokers had hypertension compared to 70% of non-smokers which is statistically significant (P<0.05) (Table 6). Similarly alcoholics had increased risk (88. 89% vs. 70. 83%, P<0.05) compare to non-alcoholics for hypertension (Table 7).

DISCUSSION: This study revealed overall prevalence of hypertension among CKD patients admitted into the nephrology ward over a period of six months to be 82.35%, which corresponds to the figure of 80% noted by a study done by Dr. Ronald M, Goldin et al. (1) The prevalence of hypertension was progressively increasing with the severity of CKD; 9.52% of the hypertensive patients were in stage (3), and 90.48% in stage 4-5 CKD. Based on a national survey of representative sample of non-institutionalized adults in the USA, it is estimated that hypertension occurs in 23.3% of individuals without CKD, and 35.8% of stage 1, 48.1% of stage 2, 59.9% of stage 3, and 84.1% of stage 4-5 CKD patients. (6)

A study done by J. A. Whitworth et al showed that more than half the patients with CKD die from a cardiac or vascular event. (4) In a study done by He J et al it was found that adults using healthy lifestyle changes were six times more likely to have controlled hypertension. (7) Study done by Coresh et al. 2003 in their NHANES III Cross-sectional Survey revealed that 51.4% of those with Hypertension on no medication and 64. 4% of those with Hypertension on medication had reduced GFR. (8)

Segura et al. 2004 (83) in their Observational cohort study looking at relationship between blood pressure and CKD observed that among patients with essential hypertension and normal renal function at baseline and a mean follow-up of 13.2 years, 14.6% developed renal insufficiency. (9)

CONCLUSIONS: This study revealed prevalence of hypertension among CKD patients to be 82.35%. Increasing age (>40 yrs.) had a significant association with hypertension among CKD patients. Individuals with hypertension and family history of CKD had increased risk of developing CKD. Smoking and Alcohol consumption had a significant association with hypertension among CKD patients. Presence of hypertension had an increased risk for heart disease among CKD patients. Inadequately controlled hypertension had significant association with occurrence of heart disease.

RECOMMENDATIONS: All efforts should be made to detect and strictly control hypertension in prevention and management of CKD. As an initial step, individuals aged more than 40 years and with family history of CKD should be screened for hypertension and CKD. Increased efforts are needed to identify the reasons for inadequate control of hypertension and approaches to increase blood pressure control among patients with CKD. Changes in life style (smoking, alcohol) are also necessary for control of hypertension along with pharmacological treatment. CKD patients with hypertension should be regularly screened for cardiovascular disease.

DOI: 10.14260/jemds/2015/731

ACKNOWLEDGEMENTS: The authors are grateful for the support given by Dr A. Sree Devi, Prof and HOD, Department of community medicine and Dr N. Jikki, Prof and HOD, Department of Nephrology, Kurnool Medical College.

REFERENCES:

(1.) Dr. Ronald M. Dr. Goldin MD at al. Hypertension and CKD. Issue of kidney beginnings: The magazine, 2005; 4: 1.

(2.) Modi GK, Jha V: The incidence of end-stage renal disease in India: a population-based study. Kidney Int 2006, 70 (12): 2131-3.

(3.) Leticia Buffet, PharmD, Charlotte Ricchetti, PharmD, BCPS, CDE Chronic Kidney Disease and Hypertension A Destructive Combination http://www.medscape.com/.

(4.) JA Whitworth et al. Progression of Renal Failure--The Role of Hypertension. Ann Acad Med Singapore: 2005; 34: 8-15.

(5.) US Department of Health and Human Services. National institute of health, USA. Seventh report of the Joint national committee on Hypertension (JNC-VII). December 2003.

(6.) U S Renal Data System, USRDS 2010 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Bethesda, Md, USA, 2010.

(7.) He J et al. Factors associated with hypertension control in the General population of the United States. Arch Intern Med. 2002; 162: 1051-1058.

(8.) Coresh J, Aster BC, Greene T, Eknoyan G, Levey A S Prevalence of Chronic Kidney Disease and Decreased Kidney Function in the adult U S population: Third national health and nutrition examination survey. Am J Kidney Dis (2003) 41: 1-12.

(9.) Segura J, Campo C, Gil P, Roldan C, Visi I L, Rodicio JL et al. Development of Chronic Kidney Disease and cardiovascular prognosis in essential Hypertensive patients. J Am Soc Nephrol. 2004; 15: 1616-1622.

Y. Padma Sri [1], T. Siva Kala [2]

AUTHORS:

[1.] Y. Padma Sri

[2.] T. Siva Kala

PARTICULARS OF CONTRIBUTORS:

[1.] Associate Professor, Department of Community Medicine, Kurnool Medical College, A. P.

[2.] Senior Resident, Department of Community Medicine, RIMS, Ongole, A. P.

FINANCIAL OR OTHER COMPETING INTERESTS: None

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Y. Padma Sri, Associate Professor, Department of Community Medicine, Kurnool Medical College, Kurnool, Andhra Pradesh.

E-mail: padmasriyalamanchili@yahoo.co.in

Date of Submission: 12/03/2015.

Date of Peer Review: 13/03/2015.

Date of Acceptance: 26/03/2015.

Date of Publishing: 08/04/2015.
Table 1: Hypertension and socio-demographic distribution
of the study subjects

                            Hypertension   Hypertension
Socio demographic factors     present         absent      P-value

Male                        89 (84.76%)    16 (15.24%)

Female                      37 (77.08%)    11 (22.92%)     >0.05

< 40y                       17 (65.38%)     9 (34.62%)     <0.05

[greater than or            109 (85.83%)   18 (14.17%)
equal to] 40y

< 12y of education          108 (81.20%)   25 (18.80%)     >0.05

> 12y of education            18 (90%)       2 (10%)

BPL                         114 (82.01%)   25 (17.99%)     >0.05

APL                         12 (85.71%)     2 (14.29%)

Table 2: Hypertension Vs Stage of Chronic kidney Disease

                                                            [chi
                                                          square]
                CKD stage 3   CKD stage 4      Total       value:

Hypertensives   12 (9.52%)    114 (90.48%)   126 (100%)   5. 5001
Normotensives   7 (25.93%)    20 (74.07%)    27 (100%)    P-value:

Total           19 (12.42%)   134 (87.58%)   153 (100%)    < 0.05

Table 3: Hypertension and Family history of Chronic Kidney disease
among CKD patients

                  Family history of CKD

Subjects          Present        Absent        Total      [chi square]
                                                             value:

Hypertensives   29 (23.02%)   97 (76.98%)    126 (100%)      6.2425
Normotensives     0 (0%)       27 (100%)     27 (100%)
                                                            P-value:
Total           29 (18.95%)   124 (81.05%)   153 (100%)      < 0.05

Table 4: Hypertension vs Heart disease among Chronic kidney Disease
patients

                      Heart disease

Subjects          Present        Absent        Total      [chis quare]
                                                             value:
Hypertensives   20 (15.87%)   106 (84.31%)   126 (100%)      4.9302
Normotensives     0 (0%)       27 (100%)     27 (100%)
                                                            P-value:
Total           20 (13.01%)   133 (86.93%)   153 (100%)      < 0.05

Table 5: Control of Hypertension Vs Heart disease among CKD patients

                      Heart disease

Hypertension      Present        Absent        Total      [chi square]
                                                             value:
Under control    3 (4.35%)    66 (95.65%)    69 (100%)      15.1721

Inadequate      17 (29.82%)   40 (70.18%)    57 (100%)
control
                                                            P-value:
Total           20 (15.87%)   106 (84.13%)   126 (100%)      < 0.05

Table 6: Smoking Vs Hypertension among Male Chronic
kidney Disease patients (n=105)

Smoking   Hypertensives   Normotensives     Total

Present    75 (88.24%)     10 (11.76%)    85 (100%)
Absent      14 (70%)         6 (30%)      20 (100%)
Total      89 (84.57%)     16 (15.24%)    105 (100%)

[chi square] 4. 1683 P = 0.04.

Table 7: Alcohol vs. Hypertension among Male Chronic kidney Disease
patients (n=105)

Alcohol consumption   Hypertensives   Normotensives     Total

Yes                    72 (88.89%)     9 (11.11%)     81 (100%)
No                     17 (70.83%)     7 (29.17%)     24 (100%)

Total                  89 (84.76%)     16 (15.24%)    105 (100%)

[chi square] = 4.6730, P = 0.03.

Figure 1: Hypertension and diagnosis of
Chronic kidney disease

Before diagnosis of CKD             69 (54.76%)
At the time of diagnosis of CKD     40 (31.75%)
After the diagnosis of CKD          17 (13.49%)

Note: Table made from bar graph.
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Title Annotation:ORIGINAL ARTICLE; Government General Hospital, Kurnool, India
Author:Sri, Y. Padma; Kala, T. Siva
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Apr 9, 2015
Words:1966
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