HYPERTENSION SECONDARY

TO LUPUS (SLE)Minor Case Study

By: Amanda Hunter, Dietetic Intern

CASE STUDY PATIENT: MW

Admitting Dx: Uncontrolled high blood pressure, leukopenia, microcytic anemia

Hx: Lupus (SLE), lupus nephritis, HTN, pulmonary embolism, transient ischemic attack

Height: 158cm (5’2”) Weight: 51.5kg (113.5lbs)

Age: 42yo Sex: Female

Social History:

Occupation: clerk at Walgreens Marital status: Single

Children: 1 daughter, 18yoReligion: Christian

CASE STUDY PATIENT: MW

Objective:• Why chosen?

• Focus of study: HTN in patients with Lupus

• Pathophysiology

• Complications

• Treatment

PATHOPHYSIOLOGY OF SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

• SLE is an autoimmune disease where the immune system attacks tissues and causes inflammation

• Symptoms vary

• Organs most often affected: skin, kidneys, cardiovascular system, nervous system, connective tissue, muscular system

• Lupus is most common in women of childbearing age (15-44yo)

• Lupus is also more likely to develop in African-American, Asian American, Native American, and Latina women compared with Caucasian women (1)

• Hypertension affects 14-58.1 % of patients with SLE, varies with ethnicity(1)

• Lupus nephritis results when lupus causes kidney inflammation

SYMPTOMS OF LUPUS

The most commonly occurring symptoms of lupus include:

• Intense fatigue

• Painful and/or swollen joints

• Muscle pain

• Red rash on the face and/or in response to sitting in the sun

• Pain in the chest after taking a deep breath

• Unexplained fever

• Edema (swelling), often in the legs or around the eyes

• Mouth sores

• Unexplained hair loss

• Raynaud’s phenomenon, which is characterized by cold fingers and/or toes that are pale or purple in color.(2)

DIAGNOSIS OF LUPUSWHEN 4 OR MORE OF FOLLOWING EXIST

CRITERION SIGNS/SYMPTOMS TEST

Malar rashA red rash on the cheeks and the bridge of the nose; often called a "butterfly rash"

Physical exam, medical history

Discoid rash Raised, hard patches of scaly skin Physical exam, medical history

Photosensitivity A red skin rash caused by exposure to sunlight Physical exam, medical history

Oral ulcers Sores in the mouth, usually painless Physical exam, medical history

Nonerosive arthritisInflammation in one ore more joints, making them feel tender and swollen. Cartilage, which is protective tissue surrounding the bone, remains intact

Physical exam, medical history, X-ray

Pleuritis and/or pericarditisInflammation of the lining of the lung or heart, respectively; may cause pain when breathing deeply; growing tired easily

Lung function test; chest X-ray to look for fluid in the lungs; cardiac stress test; echocardiogram, which uses sound waves to visualize the heart

Neurologic disorderReduced or abnormal brain function, headaches, seizures, memory loss, difficulty concentrating

Physical exam, medical history, brain MRI (magnetic resonance imaging); produces a high-resolution image of the brain.

Kidney DisorderUsually no symptoms; signs are blood or high levels of protein in the urine.

Urinalysis

Blood disorderAnemia (low red blood cell levels) with associated fatigue, dizziness, shortness of breath; increased susceptibility to infection; slow clotting, excessive bleeding

CBC (complete blood count); test for abnormal cell counts of platelets, red blood cells, lymphocytes, and/or leukocytes

Immunologic disorderPossible increased susceptibility to infection, inflammation in various organ systems

Assorted tests to detect antibodies from a blood sample.

Positive anti-nuclear antibodiesPossible increased susceptibility to infection, inflammation in various organ systems

ANA (antinuclear antibody) test; test for the presence of antibodies that bind the cell nucleus, which is where the DNA that make up genetic material is stored

PAST MEDICAL HISTORY OF MW

• 2003: Dx Systemic Lupus Erythematosus

• 2008: Lupus flare caused ER admittance and blood transfusion.

• Pt given high dose steroids with a taper.

• Pt has been on / off steroids since diagnosis in 2003.

• June 20, 2011: Dx: Avascular necrosis of humeral head, lupus nephritis.

• Joint pain and swelling in knees, shoulder, back, and hands related to lupus flare.

• Pt reports has not had flare to this degree since 2008

PRESENT MEDICAL HISTORY OF MW

• Patient’s Symptoms upon admission:

• Uncontrolled high blood pressure: 180’s with peak at 220/30 mm Hg.

• History of SLE

• Leukopenia: Low WBC

• Microcytic anemia: Low Hgb and Hct

• Low GFR

DISEASE CONDITION

• Lupus is a systemic autoimmune disease

• attacks tissues in the body

• causes inflammation

• Lupus affects around 1.5 million Americans

• Lupus is most common in women of childbearing age (15-44yo) (2)

• Patient MW was diagnosed with Lupus in 2003.

• The symptoms of Lupus can vary for each person

• MW’s organs most affected by Lupus are her cardiovascular system and kidneys

TREATMENT OF LUPUS

• Immunosuppressants to treat Lupus

• steroids, cyclophosphamide, azathioprine, and mycophenolate mofetil.

• Improved the mortality rate of SLE and lessened the amount of acute manifestations.

• long term outcomes of SLE have not improved over the last 30 years.

• Side effects of high-dose steroids and cyclophophamide

• Increased risk of infections contributes to the overall mortality in patients with SLE.

• Search for new drugs that more specifically control the autoimmune response of SLE with fewer side effects. (4)

TREATMENT OF HYPERTENSION

• HTN risk for cardiovascular diseases

• HTN contributes to 54% stroke deaths, 47% deaths from CHD

• Preventing HTN through dietary intervention

• Trials show reducing sodium reduces ave BP

• Potassium intake negatively associated with BP

• AND ‘s recommended nutrition therapy for HTN is DASH diet

• Sodium less than 2400mg / day

• Increase fruits, veg, whole grains

LAB VALUESLab 12/01/2014 High /

Low12/01/2014 High /

LowPossible Indications

WBC 2.23 Low 2.46 Low  Hgb 11.5 Low 11.4 Low AnemiaHct 36.6% Low 35.9% Low anemiaMCH 24.9 Low 24.6 Low  RDW 15.9% High 15.9% High  Neutrophils 0.98 x 10’3 Low 1.26 x 10’3 Low  

Lymphocytes

0.92 x 10’3 Low 0.90 Low  

BUN 8mg / dL Normal 12 mg / dL Normal  

Creatinine 1.14 mg / dL High 1.05 mg / dL High  Calcium 9.1 mg / dL Normal 8.8 mg / dL normal  

GFR 63.2   69.5   CKD stage 1UA protein Trace amts   n/a    Albumin 3.7 Normal n/a    

Total Pro 8.2 High n/a    AST enzyme 34 High n/a    

ALT enzyme 11 Normal n/a    

MEDICATIONS

Home Medication

Dosage Use Interactions

Norvasc 2.5mg HTN Other BP meds

Tylenol Extra Strength

500mg every 4hrs, PRN

Pain / fever Blood thinners

Atenolol 25mg daily HTN, agina Alcohol

Clinical Medication

Dosage Use Interactions

amlodipine 10mg daily Treat HTN, Ca channel blocker

 

Hydralazine 25mg, 4x/day Treat HTN and HTN emergencies

 

Enoxaparin 40mg / day Prevent blood clots

Blood thinners

MEDICAL NUTRITION THERAPY Nutrition history: The patient does not follow a therapeutic diet at home

• Tries to eat less sodium by not eating anything from a can

• Eats fast food and ready-to-eat foods while working at Walgreens.

• Limited time to cook at home

• Current prescribed diet: Cardiac diet d/t diagnosis of HTN and uncontrolled high blood pressure.

Patient’s response to the diet: Agreeable and well tolerated

MEDICAL NUTRITION THERAPY Nutrition related problems:

• Uncontrolled high blood pressure

• Pt was admitted to the ER for high BP

• 180’s and peak 220/130 mm Hg.

• Hx of HTN for past two years

• Pt has prescription for Norvasc 2.5mg, stopped taking 1wk prior

Present nutritional status:

• good and stable.

• Uncontrolled high BP resolved

• BP of 140/90 upond d/c

• Cardiac diet instruction, emphasis on reducing sodium intake

• Estimated calorie needs: 1800kcal / day (35kcal / kg) (7)

• Estimated protein needs: 42g protein / day (0.8g / kg) (7)

PATIENT’S NUTRITION EDUCATION PROCESS

• Pt currently tryng to eat less sodium

• Diet recall revealed pt salts food at home and when dining out

• Pt uses condiments in excess

• Pt often consumes Chinese food

• Diet education provided base on assessment:

• Foods to limit or avoid

• Salt free seasoning alternatives

• Recommended salt intake of 2400mg or less

• Eating out pamphlet provided with sodium intake

PROGNOSIS• Pt discharged w/ BP controlled at 140/90 mm Hg

• Prognosis is largely dependent on the patient’s adherence to medical and dietary recommendations.

• Hx of hospitalizations for complications related to SLE after stopped taking meds for HTN

• Physician encouraged the patient to be consistent in taking her medication for hypertension in order to lower her risk of kidney failure

• Pt was encouraged to follow the low-sodium guidelines and make dietary changes.

• Understanding of the prescribed diet was good, but motivation to change was low to fair.

• Pt was receptive to education and written resources.

BIBLIOGRAPHY

1. Choe J-Y, Park S-H, Kim J-Y, Jung H-Y, Kim S-K. A Case of Systemic Lupus Erythematosus Presenting as Malignant Hypertension with Hypertensive Retinopathy. The Korean Journal of Internal Medicine 2010;25(3):341-344. doi:10.3904/kjim.2010.25.3.341.

2. Lupus: Systemic Lupus Erythematosus. January; 2014 ; Available from: http://www.lef.org/protocols/immune-connective-joint/lupus/Page-01 (Accessed December 2014 ).

3. Roven, B, Lupus Nephritis. February ;2014 ; Available from: http://kidney.niddk.nih.gov/kudiseases/pubs/lupusnephritis/#what (Accessed December 2014 ).

4. Lech, M, ;The Pathogenesis of Lupus Nephritis January ;2013 ; Available from: http://jasn.asnjournals.org/content/24/9/1357.abstract (Accessed December 2014).

5. Zhang Z, Cogswell ME, Gillespie C, et al. Association between Usual Sodium and Potassium Intake and Blood Pressure and Hypertension among U.S. Adults. October 2013; Available from: http://www.ncbi.nlm.nih.gov/pubmed/24130700 (Acessed December 2014).

6. Hypertension. January ;2014 ; Available from: https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5803&lv2=8480&ncm_toc_id=8480&ncm_heading=Nutrition%20Care (Accessed December 2014 ).

7. Mahan, L. Kathleen., Escott-Stump, Sylvia., Raymond, Janice L.Krause, Marie V., eds. Krause's Food & The Nutrition Care Process. St. Louis, Mo. : Elsevier/Saunders, 2012. Print.