The patient is a 57 years old male called Mr. Y. He is an Asian with a height of 1.60 m and weighs 54kg. His calculated BMI is 21. He is a Muslim and he is married with no child. He complained of nausea for 2 days, he had generalized body weakness and he felt giddy, malaise and lethargy for a week and he lost his appetite for 3 days. He also had intermittent productive cough for 2 days. His was admitted to the emergency ward during noontime through referral from another clinic because he was anaemic and he had generalized body weakness for a week. He was also being diagnosed with urosepsis and acute attack of chronic renal failure by the clinic. His past medical history showed he had hypertension for 2 years, Diabetes mellitus (DM) for 2 years and advanced renal failure for 2 years. He is a smoker who had been smoking for 20 years with 15 cigarettes per day. However, he doesn't drink alcohol. He stays with his wife and his parents in a normal housing area. He was a manager in a bank but he is unemployed currently due to his deteriorating health. He rarely travels abroad to anywhere because he was busy with his occupation. He does not have any relevant family history.
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His drug history chart showed he was on Isophane insulin 16 units subcutaneous (s/c) twice daily and Metformin 500mg tablet three times daily for (DM) and also Nifedipine 10mg tablet three times daily for hypertension 2 years ago. During the subsequent year, he was being prescribed Gliclazide 80mg tablet once daily for DM and also Prazosin 2mg tablet twice daily and Perindopril 4mg tablet once daily for his hypertension. He was also being prescribed Vitamin B complex 2 tablets once daily. He does not take any traditional medicine or any herbal remedies and he has no known food or drug allergy.
Upon examination, Mr. Y was generally weak and he lost some weight recently due to his lack of appetite. He also couldn't sleep well lately and he felt lethargic all the time. Physical examination was carried out on him and he was alert, conscious and cooperative. His abdominal examination went well and he had no abnormalities in his abdomen. Stool samples were taken and he had soft brownish stools. His blood pressure was 110/61 mmHg and his pulse rate was 75 bpm. His temperature was 37oC. All of his vital signs are normal except for his respiratory rate. The hospital carried took blood samples from him and the blood test result showed he had low red blood cell count of (3.1 x 1012/L) compared to reference range of (4.5-5.9 x 1012/L) and his haemoglobin count of 8.7 g/L is also lower than the reference range of (13.7-17.5 g/L), indicating he is still anaemic when he was admitted to the hospital. His white blood cell count of (22.6 x 109/L) are way higher than the reference range of (5.3-12.4 x 109/L), indicating he had an infection prior to admission to the hospital. The hospital also carried out blood pH test which indicated he had metabolic acidosis due to DM. His HbA1C test for DM is 5.9%, which is within range of the reference value of lesser than 6.5%.
Mr. Y's respiratory rate was a bit higher than usual, which is 22 breaths per minute. His arterial blood gases were normal except for his blood pH. His blood pH was 7.33, which is lower than the reference range of (7.35-7.45). He had intermittent productive cough with green sputum for 2 days straight. Physical examination showed that he had lower right lobe haziness and bibasal crepitations in the lungs. However, he didn't complain of having shortness of breath nor any chest pain. Examination of his renal profile showed he had elevated levels of urea, potassium and creatinine concentrations. He also had decreased levels of Na+ and Ca2+. These are all indications that his renal function is deteriorating. Table 1 would have the summary of all the lab findings. His calculated creatinine clearance (CrCl) is 8.08 ml/min, indicating he is at the last stage of renal failure, which is end stage renal failure. However, there was no microalbuminuria present in his urine. The patient had renal failure since 8 years ago and he had been diagnosed with end stage renal failure 2 years ago. He was also being diagnosed with hypertension 2 years ago.
Patient had a few co-morbidities namely hypertension, end stage renal failure and diabetes mellitus. End stage renal failure (ESRF) is a disease state when a patient's kidney function deteriorated to a certain level whereby the only way the patient can carry on their life is by dialysis process or by performing kidney transplantation [1] . A patient is classified to have end stage renal failure when his glomerular filtration rate (GFR) is lesser than 15 mL/min [2] . The prevalence rate for chronic kidney disease is 8.7-18.7%, where lesser than 1% of them will develop ESRF [3] , [4] . The kidney function could be damaged by other disease such as hypertension, diabetes mellitus, glomerulonephritis, pyelonephritis, renovascular diseases and inherited diseases such as polycystic kidney disease [5] , [6] . When certain parts of the kidney had been damaged, the undamaged glomerulus will filter substances at a higher rate, which will subsequently mask the symptoms of renal function deterioration until 10-15% of the kidney function remains5. The lost of kidney function will cause electrolyte imbalance and build up of fluid, leading to oedema, hypertension and heart failure5. Symptoms of ESRF include anaemia, loss of appetite, oedema, and fatigue. Diagnosis of ESRF can be done by measuring the serum creatinine level and blood urea concentration5. If the creatinine level is more than 120 µmol/L, the patient is considered to have significant kidney failure5. Table 3 summarizes the stages of kidney failure before reaching ESRF through measuring GFR.
Once patient reaches ESRF, there are only a handful of renal replacement therapy options to maintain their quality of life. This includes haemodialysis, peritoneal dialysis (PD), or kidney transplantation5. Haemodylisis is a process whereby blood is extracted out and transferred to a dialyser which has a semi-permeable membrane that'll filter out excess fluid and toxic solutes through passive diffusion2,5. In Asia, 10-20% of patients are treated with PD. PD fluid is introduced into the abdomen through a catheter and substances diffuse into the fluid, which will then being excreted out from the peritoneal cavity5. Kidney transplant is the best outcome for ESRF patient but high cost, shortage of organ donors and difficulties in getting a suitable organ match for patients render this treatment option to be carried out to all ESRF patients [7] .
Hypertension is a condition whereby patient's blood pressure (BP) is being elevated to more than 140/90 mmHg. There are 2 types of hypertension which are primary (essential) and secondary hypertension. The causes for essential hypertension which affects 90 to 95% of hypertensive patients are unknown but it includes environmental and genetic factors [8] . The rest of the hypertensive population had secondary hypertension, where other co-morbidities such as renal disease and certain endocrine diseases or even pregnancy caused elevated BP. Hypertension is asymptomatic, therefore it's also known as "the silent killer". Regular screening is vital to detect early signs of hypertension2. Hypertension is a major cause for cardiovascular diseases such as stroke and myocardial infarction2. The overall prevalence for hypertension is 27.8% and it increases with age and dietary habits. Individuals with family history of hypertension are twice as likely to develop the disease and obese people (BMI≥30) are 8 times more likely to develop hypertension than population with a normal BMI of lesser than 18.5 [9] . A person with a BP of more than 140/90 mmHg is considered to be hypertensive. However, the choice whether to commence treatment depends on whether the patient has other co-morbidities such as DM or high risk for coronary events. A patient with a BP of more than 160/100 mmHg is considered to have malignant hypertension and should be treated2. Since Mr. Y is also a diabetic patient, his target BP should be maintained at lesser than 130/80 mmHg. The treatment adapted from SIGN guidelines for hypertension is being explained in the diagram below (Figure 1).
As Mr. Y was admitted due to anemia, therefore the main concern is to maintain his quality of life even if he has ESRF. However, the patient is already on PD and the only way to improve his kidney function to produce erythropoietin and stimulate the production of hemoglobin is through kidney transplantation. For now, patient was given packed cells which are basically blood transfusion during PD. Studies on efficacy of packed cells for anaemia. However, I had suggested another less troublesome alternative for the patient, which is the introduction of recombinant human erythropoietin (rhEPO) such as Darbepoetin alfa subcutaneous injection 450 ng/kg once weekly. A study involving treatment using rhEPO administered 2 to 3 times per week showed that rhEPO significantly increase hemoglobin levels in patients treated with PD without causing any significant changes towards blood presure [11] . Another study that used rhEPO showed that it helped to increase and maintain the hemoglobin level to an average of 108 ± 15 g/L after 3 months [12] . Moreover, Darbepoetin alfa had to be injected only once every week and this will subsequently increase the compliance of patients for this treatment.
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Treatment options for hypertension as mentioned in Figure 1 above showed that the first option for managing hypertension is through the administration of a calcium channel blocker or a thiazide type diuretics since Mr. Y is more than 55 years old. Thiazide type diuretics such as Bendroflumethiazide had to be avoided in patients with CrCl of <30ml/min because it'll be ineffective and therefore not suitable for Mr. Y. He had been given nifedipine, which is a calcium channel blocker 2 years ago but it had been withdrawn due to unknown reasons. The patient was prescribed perindopril, which is an ACE inhibitor and prazosin, an alpha blocker for treatment of hypertension. A study involving hypertensive patients with DM showed perindopril is just as effective in lowering systolic and diastolic blood pressure as candesartan, an angiotensin receptor blocking drug [13] . The study also showed that perindopril didn't significantly increase BMI or HbA1C level. In another randomized controlled trial, perindopril is found to be equally effective once daily as the twice daily regimen. Therefore this justifies the reason why perindopril once daily dosage had been prescribed for Mr. Y. Moreover, comparative studies also showed that perindopril is better than other ACE inhibitors in lowering BP [14] . Prazosin is an alpha blocker which is only being recommended in step 4 for treatment mentioned by the NICE guideline. A study showed that prazosin significantly reduces BP in patients that undergo dialysis treatment [15] . A comparison study between prazosin to atenolol, an alpha blocker showed that prazosin is more effective in reducing either 10 mmHg or reduction to 89 mmHg or below for diastolic blood pressure than atenolol [16] . Unlike atenolol, prazosin doesn't affect the lipid levels and therefore it does not contribute to risk of developing coronary diseases.
For treatment of pneumonia, patient had been prescribed with IV Ceftriaxone. However, in a study comparing IV gatifloxacin against IV ceftriaxone for treatment of pneumonia, IV gatifloxacin is significantly more effective than IV ceftriaxone in eradicating the disease within 3 days and it is just as easily tolerated by patients as IV ceftriaxone [17] . However, in another study done in Pennsylvania, Ceftriaxone was significantly more effective in eradicating community acquired pneumonia compared to ertapenam, indicating IV ceftriaxone is still an effective treatment for pneumonia [18] . According to BNF, ceftriazone had to be monitored in patients with severe renal impairment of creatinine clearance of lesser than 10 mL/min, which is applicable in this case where Mr. Y's creatinine clearance is only 8.08 mL/min. Therefore, if the patient's condition improves, the dosage for IV ceftriazone can be reduced to lesser than maximum of 2mg daily or even withdraw if the patient had fully recovered.
Patient was also been prescribed ranitidine 150mg twice daily due to abdominal pain. However, this is not the recommended dose by the BNF for patients with renal impairment with CrCl of lesser than 30 mL/min. The recommended dose is half of the normal dose, which is 75mg twice daily. Trials on efficacy for half the dosage of Ranitidine.
In conclusion, the management for hypertension of this patient was not being dealt correctly by the hospital and doctors. Patient was not being given any anti-hypertensive during his hospital admission. Therefore, there is a need for the doctors to make a serious attempt in managing this patient's hypertension problem. There is also another issue regarding this patient's anaemic problem. The hospital should find another better alternative such as rhEPO rather than providing the patient with packed cells during PD as the effect of this treatment is not as long lasting as rhEPO and it wouldn't help patient with compliance problem.
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