Drug Related Problems Complication In Hypertension Disease,

Chronic Kidney Disease And Type II Diabetes

Syahrul Tuba1)
(Corresponding author)
Tel : +62853-9511-7731
Email : syahrulpharm@yahoo.com
Diana Laila Ramatillah2)
1,2)

Faculty of Pharmacy, Tujuh Belas Agustus 1945 University, Jakarta, Indonesia

Abstract
Hypertension is a disease that often occurs in the Ward Internal Medicine Persahabatan Hospital
in Jakarta. Hypertension is widely known as cardiovascular disease. 1 Estimated for hypertension
that it has caused 4.5% of the global burden of disease, and the prevalence is almost as large in
developing countries and in developed countries. 1 Hypertension is one of the major risk factors
for heart problems.1 In addition to causing heart failure, hypertension can lead to kidney failure
and cerebrovascular disease. 1 In most cases, hypertension was detected on physical examination
for reason of certain diseases, so it is often referred to as the "silent killer".2 Unwittingly patients
experienced complications in vital organs such as the heart, brain or kidneys. 2 The population of
the world who have diabetes mellitus tended to increase from year to year, it is due to the
increasing number of population, lifestyle, increasing prevalence of obesity and lack of physical
activity.3 Reports from WHO on diabetes population studies in various countries, the number of
people with diabetes mellitus in 2000 in Indonesia ranks 4th in the number of people with
diabetes mellitus with the prevalence of 8.4 million people, in 2010 the number of people with
diabetes in Indonesia at least be 5 million and 239.9 million people in the world, estimated in
2030 the prevalence of diabetes mellitus in Indonesia increased to 21.3 million. 4 Morbidity and
mortality due to diabetes mellitus in Indonesia tend to fluctuate each year in line with the lifestyle
changes that lead to fast food and fiber carbohydrates. 4
Case Presentation : Ms. SJ 46-years-old woman hospitalized in internal medicine ward. Patient
was diagnosed with the disease complications of hypertension, chronic renal failure and diabetes
type II, and hypoalbuminemia.
Clinical Evaluation : interventions to do that lower the dose of valsartan, treatment of drug
interactions between Askardia with Gliquidone, and not given albumin..
Keywords: Hypertension, CKD, Diabetes Type II

1. Introduction
Hypertension is widely known as cardiovascular disease.5 Estimated to have
caused 4.5% of the global burden of disease, and the prevalence is almost as large in
developing countries and in developed countries.5 Hypertension is one of the major
risk factors for heart problems.5 In addition to causing heart failure, hypertension can
lead to kidney failure and cerebrovascular disease.5 The disease is responsible for the

high cost of treatment due to the reasons for the high number of visits to the doctor,
hospital care and / or long-term drug use. 5 In most cases, hypertension was detected
on physical examination for reason of certain diseases, so it is often referred to as the
"silent killer".6 Unwittingly patients experienced complications in vital organs such
as the heart, brain or kidneys.6
Chronic kidney disease can lead to hypertension and otherwise on chronic
hypertension can lead to kidney disease. 7 Under normal conditions contained in the
autoregulation of renal blood flow which allows the presence of the remains of the
kidney filtration rate while keeping the mean arterial pressure glomerolus of 80-160
mmHg.7 This mechanism goes through a reflex mechanism of myogenic and
tubuloglomerular feedback.7
Diabetes mellitus is a group of diseases characterized by insulin insufficiency
disease or failure of adequate response to insulin, causing hyperglycemia.8 Diabetes
is the most common chronic diseases in the world, affects about 180 million people
in 2008, and an estimated 360 million people in 2030. 8 Five to 10 percent of a type-1
(insulin dependent) and 90% to 95% are type 2 (not insulin dependent).8
Heart failure has become a problem in the health sector in recent years, and is
the cause of hospitalization for patients over 65 years. 9 Diabetes mellitus is an
independent risk factor for the development of heart failure.9 Several studies indicate
that there is a risk of heart failure approximately 2 times higher in men and 5 times
higher in women with diabetes.9 This relationship is even more elevated in younger
patients (<65 years), to 4 times and 8 times higher in men and women with diabetes
compared with patients without diabetes.9
2. Case Presentation
SJ is a 46-years-old woman hospitalized in internal medicine ward (Internist).
Patient entered Persahabatan Hospital on the 15th of March 2014 in the Emergency
room (ER) with complaints of shortness of breath become heavy, especially when
lying down sleeping, coughing, and throat felt dry, the patient has a history of
diabetes since 2 years ago with only patient taking the drug Metformin. Having
conducted several clinical interventions particularly blood and urine laboratory tests
and in reference to the disease ward Internist with was diagnosed of type II diabetes,

chronic kidney disease (CKD) and hypertension on March 18, 2014. The patient was
diagnosed with hypertension with blood pressure 160/100 mmHg, CKD on dialysis
with serum creatinine 6.5 mg/dl and she have being 2 times a week hemodialysis,
diabetes mellitus type II disease with while blood glucose 198 mg/dl, and diagnosed
hypoalbuminemia with value of albumin 2.7%.
As for drug therapy was given to patient Ms. SJ were Askardia aims to thin the
blood that occurs in patient on March 20th and on March 21th 2014, while for the
drugs treatment of hypertension given valsartan 160 mg once a daily since her first
day in the ward Internist, amlodipine 5 mg once a daily since the first day of the ward
in internist, clonidine 0.15 once daily start on March 22th to March 25nd 2014.
Furosemide 40 mg once a daily starting on March 22th, 2014 to 26nd March. The
treatment of chronic kidney disease (CKD) using CaCO3 drug since the first day of
the disease ward internist and folic acid given on March 18th, 2014 to March 21nd.
Therapy of type II diabetes using insulin medication was given on the March 18th
2014, and March 19nd and 30 mg Gliquidon 1x1 / 2 was granted on March 20th
2014, to March 26nd.
The results of laboratory tests :
Examination

Result

Normal

Neutrofil

81.8 %

50-70 %

Limfosit

8.7 %

2-6 %

Monosit

8.4 %

2-4 %

Eosinofil

0.5 %

2-4 %

Eritrosit

2.86 m/uL

3.6-5.8 m/uL

Hemoglobin

8.3 g/dl

12.0-16.0 g/dl

Hematokrit

25 %

35-47 %

RDW-CV

16.3 %

11.5-14.5 %

Ureum

72 mg/dl

20-40 mg/dl

Creatinin

3.9 mg/dl

0.8-1.5 mg/dl

While Blood Glucose

185 mg/dl

<140 mg/dl

Albumin

2.7 g/dl

3,8 5,1 gr/dl

According to laboratory results that patient had impaired renal function

characterized by decreased hemoglobin and hematocrit and increased urea and
creatinine. Patient experiencing stress or shock was characterized by decreased
eosinophils. Increased Neutrophils, lymphocytes in patient usually caused by an
infection, inflammation and pancreatitis. Patient experiencing blood disorders or
anemia characterized by decreased erythrocyte. Patient experiencing Hyperglycemia
is characterized by elevated blood glucose values while. Patient also experienced a
marked hypoalbuminemia with albumin impairment.
3. Guideline treatment of hypertension and CKD complications Diabetes On HD10
Hypertension

Diabete
s

CKD

If on target, continue monitoring

every 1-3 months.

Ace-i or ARBs

Evaluation of
blood pressure
after 2 weeks.

If it has not reached the target, increase the

dose or add a second drug of choice and
continue monitoring until it reaches the
target, note the secondary cause of
hypertension or refer if the target has not
been reached.

4. Calculation Estimate creatinine clearance (CrCl) by Cockcroft-Gault10

CrCL =

Weight (kg) x(140 age)

72 x(Cs)cr (mg %)

For women :
CrCL =

CrCL =

0.85 (Weight (kg) x(140 age)

72 x(Cs)cr (mg %)

0.85 ( 50(kg) x(140 46)

72 x(6.5mg %)

CrCL = 8.54 mL/min

5. 1 Clinical Evaluation
5.1.1 Drug Related Problem 1

Valsartan dose has used by patient Ms. SJ 160 mg once daily for treating
hypertension, but the dose was not in accordance with the guidelines, treatment of
hypertension and CKD by creatinine clearance On Hemodialysis 8.54 mL / min the
dose should be lowered to 40 mg once a daily.12
Pharmacists Intervention : doctors should be submitted to the lowered dose of
valsartan.
5.1.2 Drug Related Problem 2
Patient experiencing hypoalbuminemia but the patient was not getting drugs to
treat hypoalbuminemia.
Pharmacists Intervention : suggested giving the drug based diagnostic indication.
5.1.3. Drug Related Problem 3
The concomitant ascardia used with gliquidone can cause interactions that can
lead to an increased effect Gliquidon so can caused hypoglycemia.
Pharmacists Intervention : the use Ascardia with Gliquidone are spaced
approximately 2 hours. The intake of food/sugar must remain even though simply
applied should be limited. This is necessary to avoid hypoglycemia.
6. Conclusion
Based on the assessment of the drugs used this patient, it can be concluded that
Valsartan as antihypertensive drug, the dose should be given 160 mg once daily
lowered to 40 mg in patient with Chronic Kidney Disease (CKD) on hemodialysis.
By George R. Bayley in his book Medfacts Pocket Guide Of Drug Interaction that
uses Askardia along with Gliquidon can cause interactions that can lead to increased
Gliquidon effects that can caused hypoglycemia. 13 But in practice does not appear to
hypoglycemia. This is because hypoalbuminemia patient not treated so that the drug
concentration in the blood (protein-bound drug/albumin) be increased.13

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