Management of a 70-Year-Old Female with CKD, Hypertension, and Recurrent UTIs
The optimal management for this 70-year-old female with CKD, hypertension, and recurrent UTIs should include blood pressure control with a target of <140/90 mmHg using an ACE inhibitor or ARB, appropriate antibiotic selection for UTIs based on culture results, and avoidance of nephrotoxic agents like NSAIDs.
Hypertension Management
Blood Pressure Target
- For patients with CKD over 60 years old, the recommended blood pressure target is <140/90 mmHg 1
- Current home readings of 150/90 mmHg indicate inadequate control
Antihypertensive Therapy
- First-line therapy: ACE inhibitor or ARB is recommended for patients with CKD and proteinuria 1
- Consider replacing Exforge (amlodipine/valsartan) with separate components to allow for dose optimization of the ARB component
- Maximize ARB dose to achieve optimal proteinuria reduction and blood pressure control 1
- Add a diuretic if needed for better BP control, especially appropriate in CKD 1, 2
- Monitor potassium levels closely when using RAS blockers, especially with declining kidney function 1
Lifestyle Modifications
- Restrict dietary sodium to <2.0 g/day to enhance BP control and reduce proteinuria 1
- Regular exercise appropriate to patient's physical capabilities
- Weight normalization if applicable
- Complete smoking cessation if applicable 1
Management of Recurrent UTIs
Diagnostic Approach
- Obtain urine cultures before starting antibiotics to guide therapy 3
- Differentiate between true UTIs and asymptomatic bacteriuria, which should not be treated 3
Antibiotic Selection
- For E. coli UTIs, use trimethoprim-sulfamethoxazole with appropriate dose adjustment for renal function 3, 4
- Avoid fluoroquinolones due to increased risk of tendinopathies and other adverse effects, especially in elderly patients 3
- Adjust antibiotic dosing based on creatinine clearance:
Treatment Duration
- For recurrent UTIs in elderly females, a 7-day course is typically recommended 3
- For complicated UTIs or those with systemic symptoms, extend treatment to 10-14 days 3
Prevention Strategies
- Ensure adequate hydration (1500-2000 mL/day if not contraindicated) 3
- Consider urological evaluation given recurrent infections and CT findings of thickened bladder wall
- Evaluate for and address any urinary retention or anatomical abnormalities
CKD Management
Monitoring
- Regular monitoring of kidney function (every 3-6 months depending on stability)
- Monitor proteinuria to assess response to therapy
- Target proteinuria reduction to <1 g/day if possible 1
Medication Adjustments
- Avoid NSAIDs completely due to history of NSAID use and worsening kidney function 3
- Counsel patient to hold ACE inhibitor/ARB during periods of acute illness or volume depletion 1
- Consider adding a statin for cardiovascular risk reduction 1
Patient Education
- Educate about the importance of medication adherence
- Instruct on when to hold medications (during illness with dehydration)
- Emphasize the importance of regular blood pressure monitoring at home 5
Special Considerations
Medication Safety
- Review all medications for appropriate dosing in CKD
- Adjust Nexium (esomeprazole) and Mebeverine dosing if needed based on kidney function
- Consider home blood pressure monitoring to better assess BP control 5, 6
Follow-up
- Schedule follow-up in 4-6 weeks to assess response to therapy
- Monitor electrolytes, especially potassium, when optimizing ACE inhibitor/ARB therapy
- Consider nephrology referral for specialized CKD management given progressive decline in kidney function
By implementing this comprehensive approach, we can effectively manage this patient's hypertension, reduce UTI recurrence, and potentially slow CKD progression while minimizing medication-related complications.