MAL PRACTICE? – A true incident about the correlation between hypertension, kidney damage and negligence.

DISCLAIMER

I am not at liberty to disclose neither the identity of the patient in question nor the medical facility or the physicians’ involved in this case.

Kindly, I ask you to leave any comments you may find suitable but DO NOT ask for any information at this time. It is in the best interest of the patient.

My dearest friend “Anna” went to her primary doctor for her annual check – up last month. When she called me after her appointment she casually dropped that she had been referred to a nephrologist – kidney specialist –

“Why?” I inquired.

“Ah nothing serious, it is just that my potassium level is out of range, higher than normal and I do have anemia also. My hemoglobin is below 11.”
Anna said.

Adult standard hemoglobin range goes from 11.5 to 15 g/dl.

A red flag waved right in front of my eyes.
I know that Anna has hypertension. Her blood pressure has been elevated since her forties. She is an octogenarian now. Although she is taking medication for her blood pressure, sometimes , that is not enough to prevent kidney function deterioration.

The main two causes of kidney failure are diabetes and hypertension; in that order.

A few days later, I questioned Anna how did it go at her consultation with the kidney specialist.
She informed me that she received a sheet of paper with instructions to avoid a long list of foods and a referral for a kidney ultrasound. Diagnosis? Renal deficiency.
She had to come back to see her PCP before the ultrasound.

At that moment, I insisted on accompanying her to her PCP appointment. She accepted.

I would like to mention at this point that Anna is enrolled in a Medicare Supplement Insurance Plan.
She has been seen at the same medical facility for the last twenty years.

On the day of the consultation with my friend’s primary care doctor I encouraged Anna to request a copy of her medical records as far back as year 2010.
Within twenty minutes she received her copies and I read them carefully. My suspicion was confirmed. Anna has a condition referred to as Chronic Kidney Disease or CKD for short.
As I mentioned previously, in all likelihood, Anna’s current renal damage has been inflicted by her hypertension.

Upon reviewing the records very carefully, I discovered that my dear friend had quite more than two abnormal results in her blood work. Potassium and hemoglobin values were not the only ones out of range.

Her CBC or cell blood count did show the following values
Hemoglobin low
Red blood cell count low
Hematocrit low
All of these low values point towards one simple fact: Anemia. Anemia most likely caused by damaged kidneys that cannot produce the chemical substance needed to stimulate production of red blood cells.
Hemoglobin is the molecule that carries oxygen to all of the body cells.

Platelets : high
Iron binding capacity high

The standard chemistry panel showed several values out of range also
Phosphate ( phosphorus) high
Potassium high
Cystatin C high
Cystatin C is a protein that is measured when there is a possibility of renal dysfunction.

BUN ( Urea ) high
Creatinine high
Both these two values are biomarkers of kidney function. If they are elevated they indicate renal dysfunction.

Lipid panel
Normal as a result of medication

GFR, glomerular filtrate rate, the main biomarker of kidney function was LOW.

GFR is the single most indicative test of kidneys ability to get rid of waste and toxins from our bodies.
When there is kidney damage present, the GFR levels decrease.
The most damaged the kidney, the lower the GFR values.

GFR values are also used to establish the five stages of CKD, being number five absolute renal failure,
In common terms, the kidneys are shut down in stage number 5

Stages 1 and 2 mild damage
3 and 4 moderate damage
Stage 5 total renal failure. Need dialysis / transplant

Other lab tests that may be affected by kidney damage are

total protein,
PTH or parathyroid level – calcium is affected when PTH is at the right level.
Microalbumin, which detects kidney damage before protein is found.

These last three tests are normal in Anna’s case for the time being.

Now, I am not a doctor but I certainly do not like to see blood results out of range. I don’t think anybody does.
In order to protect my friend from patient invasion of privacy I will not disclose her exact GFR value.
Sufficient to say it is low.

Anna was taken into a small office and I went in with her.

My friend was convinced that the purpose of her visit was to receive some prescription medicine for her anemia.
To her astonishment , the doctor checked all her labs and his only recommendation was to keep her ultrasound and follow up appointments with her specialist.

At that point I intervened,
“Doctor, I reviewed my friend’s last lab report. It seems that there are quite a few tests that are out range . They all indicate kidney function deterioration. ”
“Well, this is the first time I see this patient – it was true, he was substituting for my friend’s primary physician on that day –

I see nothing in this report to be alarmed. I have patients who are much worse. Just go to see your nephrologist”. He instructed Anna.

And…that was it. I could not believe the words I heard, the indifference of the tone which they were pronounced. Above all, I could not believe that a man who supposedly took a vow to harm no one but to be an instrument of healing always could lie so deliberately to a patient, knowing perfectly well that her condition was not to be taken lightly at all.

I knew that it was pointless to argue any longer with …that man.

It turned out that later at home that evening when I reviewed all the records dating back to year 2010 that particular doctor who claimed he had never seen Anna before, had reviewed, and signed each and one of all of her lab tests results. He just never confirmed that the patient had been notified and properly instructed about the significance of those abnormal lab results. In other words, her supervisory job was sub par.

I also discovered that Anna’s first signs or evidence of kidney damage had Not been detected recently. Matter of fact, I found out that her GFR and other lab tests had been consistently marked as abnormal, some on the low side, others on the high side of their normal parameters since year 2010. ( if you remember Anna solicited a copy of her records from 2010 to present. She did not ask for a copy of previous years records)

Throughout the years, more of Anna’s chemistries have been consistently marked as out of range, indicating with all certainty that her kidneys are sustaining further deterioration.

When kidneys are damaged be it by diabetes or hypertension, its primary functions as filters of our bodies toxins become compromised. That is the reason why Anna’s potassium, phosphorus, and other blood chemistries were elevated.
Her kidneys are not healthy enough to keep all her body’s chemistries in perfect balance. They are like a good old running motor that has been hard at work for many years , executing more work that it could handled and without proper care.

Except that Anna’s kidneys are not mechanic pieces; this is a human being we are talking about. An exceptional human being adored and respected by her family and all of us who have had the privilege to met her.

Now, CKD has no cure…not yet anyway, but there are certain measures that a person afflicted by this condition can enforce to delay/ avoid further damage to their fragile organs.
I am referring specifically to the pivotal role that medications and diet play to keep the progression of the disease at bay.

Depending on the Stage of CKD a patient is in , he should be instructed to

Drink plenty of fluids ( in the last stages, when the patient enters in dialysis, fluid consumption may be limited)
Take medication to keep blood pressure not higher than 120/80. ( in some instances, more than one type of medication be required)
Control of lipids levels ( cholesterol and triglycerides) to keep them within normal range. In many cases, Anna is one of them , medication is needed to achieve desired results.
Control of blood sugar. Be it by pills or insulin if diabetes is present.

A high – carbohydrate, low – protein diet that excludes many foods rich in sodium(salt), potassium and phosphorus.
Proteins are by far the most difficult food to be metabolized by kidneys, yet, the body needs proteins to repair cells and tissues.
A good rule of thumb is to consume lean proteins in small quantities, no more than what fits in one’s hand’s palm.

Potatoes, pumpkin, spinach, nuts, wheat, broccoli, beans , multi – grain products, dairy products, desserts, sweets, fish and seafood ( yes, they have a high phosphorous content ) and unhealthy fats are some of the foods that make the black list. Yes, it is quite an extensive list because some apparently healthy foods have a high content of either sodium, potassium or phosphorous ). A CKD patient should be referred to a dietitian specialized in kidneys’ diseases. Medicare is supposed to cover this service. However, when I requested it for Anna, I was told that “her plan” does not offer the services of a kidneys’ dietitian, only dietitians they hire are for the benefit of diabetic patients.

A CKD diet is indeed a very restrictive one. Nevertheless, a CKD patient must adhere to this regimen to ensure that his kidneys remain functioning as long as possible.

No multivitamins. Only vitamins recommended by doctor
Exercise and an active life style are highly recommended.
Stress should be avoided.
Quit smoking.
Do not consume alcohol.
Avoid nephrotoxic medications, that is drugs that may damage your kidneys

These general rules should deter or delay the progression of CKD to the point of renal failure as long as possible.

How on Earth, does a patient who has not attended a Medical School is going to put in practice these measures if she is not educated by her medical practitioner?

How does the common patient with no medical knowledge is supposed to know the consequences of untreated CKD?
It is the responsibility of a medical doctor to protect the lives of those entrusted to their care. It is his duty to inform, explain and educate his patients about their illnesses and required treatments.

I am incensed, appalled and utterly in disbelief as to the way my dear friend has been neglected and kept in the darkness as to the seriousness of her ailment and the need to follow due protocol for her CKD treatment for the past few years.

I am certain, no doubts in my mind whatsoever, that if Anna would have been informed of her condition as soon as the first signs of trouble appeared, her condition would have not advanced as quickly as it had.

Anna is a very healthy, strong, active lady who has many productive years ahead of her if and only if she takes proper care of her CKD condition.

Being the case that her doctors had not educated her adequately, I took it upon myself to instruct her as to the new lifestyle she has to adopt from now on.

To summarize, Anna’s is an irrefutable example of medical practice. The medical practitioners in charge of her care have failed her blatantly.

I can’t help but wonder about the rest of the elderly and disabled patients who are being treated by Anna’s doctors.

I also wonder if we look farther past year 2010 what sort of evidence we will find?
When was exactly the first time that Anna’s lab work displayed abnormal results ?
Why was she not referred to a kidney specialist, to a dietitian from the very first moment her GFR result was out of range?
Why was she told that her potassium and hemoglobin levels are out of the normal reference values when in fact there are quite a few many other lab tests that are Out of their references values as well?
Why, why she was not advised, informed, educated? Why, even today, when the abnormal tests have proven to be quite a few, she is being shrugged off, dismissed with such an indifferent attitude?
Why does her anemic condition, present for over two years, is still UNTREATED?

Kidneys are not the only organs that sustain damage in the presence of CKD, the heart can also be severely impacted especially in the presence of untreated anemia.
Both heart and kidney damage can be reduced by careful monitoring and treatment.

CKD Statistics

An estimated 26 million Americans suffer from CKD that is, one in ten adults have some form of CKD.
There is a higher rate of CKD in patients over 65 years old.
African Americans show the greatest incidence of CKD.

The fact that both diabetes and hypertension are very common ailments in our society is the main reason I decided to share my friend’s story with all of you.

I encourage every reader who suffers from either one of these conditions or who has relatives who do to have an amicable conversation with your PCP’s especially, if you are past your prime years and discuss the results of your lab tests. Do not be afraid to ask all sorts of questions including your diet, your medications, your over- the- counter medications and supplements. Do not miss your annual check – ups. If you or a relative have been already diagnosed with either Diabetes or Hypertension take all prescribed medications and keep your blood pressure and your glucose under control.
If CKD has been already established already follow all medical advice.
Follow your diet, and take your medicines as indicated.

If you are not satisfied with the medical care you are currently receiving remember that it is “your right” to seek a second medical opinion.

This blog does NOT provide medical advice, diagnosis or treatment of any illness. Always consult a licensed medical practitioner.

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One thought on “MAL PRACTICE? – A true incident about the correlation between hypertension, kidney damage and negligence.

  1. Pingback: MAL PRACTICE? – A true incident about the correlation between hypertension, kidney damage and negligence. | cmercedes38

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