The patient had a 5:30 appointment, later than I usually like to book, but was brought in at 1:30 by a colleague who used to work with me at ABC. He came with a stack of blood tests. The kidney function was most concerning, showing that his kidneys had 26% function remaining, or stage 4 kidney disease. When I plugged the patient’s information into my kidney function calculator app, the clinical recommendation was “prepare for transplant.” Of course, there are no transplant services in Malawi. We only have dialysis available for a handful of people out of thousands who would qualify for the service in America. I wanted a few minutes, letting the patient rest in a chair, before checking his blood pressure. It was about double normal, a whopping 200/120. We call that hypertensive urgency, a pressure so high that it will cause a problem sometime, if it isn’t leading to heart attack, stroke, or end organ damage already. It wasn’t clear whether the high blood pressure was causing the kidney damage (which would mean hypertensive emergency) or if chronic poor kidney function was causing the high blood pressure, but something had to be done quickly.
The trouble is, we have a very limited number of medications available in Malawi, and even in the capital city, most of the medications available can injure kidneys further. It was easy for me to stop the diabetic medication which caused kidney damage, a bit harder to optimize blood pressure medications as the patient didn’t have a record of the medications he had been taking. We don’t have the fancy injectable medications that can be used to quickly lower medications in the US, and frankly, I’m not sure his kidneys could handle them even if we did. People with low kidney function are very sensitive; a couple weeks ago I was caring for a patient with kidneys even lower functioning than this gentleman, and when he was injected a very small amount of insulin, it dropped his sugars from 400 to 60 and would have gone low enough to knock him unconscious if we hadn’t hooked him up to a bag of glucose then. So I gave quite a bit of counseling, about diet, about medications, about how soon to expect a change, about when to come back. And we prayed together. I prayed that the medications would work and that his kidneys would miraculously improve and that he would be able to get his sugars under control. We discussed a time to meet again, and I sent him off.
I would have liked to have more time to monitor him, to watch his pressure come down, to know that he would follow up at a certain time. But I was frantically busy that day, trying to squeeze people in before the holiday, and I didn’t have the full one-hour appointments that I preferred for new patients. I had to trust my colleague, who ushered him out of the office, explaining things as he went. Only time will tell if this patient’s kidneys will improve. I am confident that the right medications and habits will help his blood pressure and sugars come down, since I’ve seen several patients with numbers and kidneys worse than his improve with the right medication and drastic lifestyle change. But whether therapeutics can help his blood pressure before he gets a stroke or a heart attack remains to be seen.
Two days later, communication with my colleague showed that the gentleman had stopped drinking, confirmed the medication that he had been taking before, and gave me a chance to advise about adding back one of the medications at ta twice-daily dosing if his blood pressures were at a certain range. And I learned that the patient had stopped drinking, whereas he was drinking a destructive amount before. So whether or not his kidneys will bounce back, whether or not we can control his chronic diseases, at least this individual is taking steps towards healing and hope.
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