Secondary hypertension caused by chronic glomerulonephritis. The tip of the iceberg

Background: Glomerular diseases, excluding diabetic nephropathy, account for about 25% of the cases of Chronic Kidney Disease (CKD) worldwide 1 , according to data until 2021 in United Kingdom the cause of chronic glomerulonephritis (GN) is 13,3%, hypertension is 6,8% 2 , while it is 14% in Indonesia according to 2018 Indonesian Renal Registry (IRR), with the highest cause is hypertension which account for 31% of CKD 3 , then 8% and 35% respectively on 2020 data 4 . There are several factors that can contribute to higher hypertension cause for CKD in Indonesia, for example, IRR got the data when the patient already on renal replacement theraphy, which maybe difficult to track down the cause which maybe already happen sometime ago, another thing is renal biopsy still low and concentrated only in some nephrology center. Objective (case illustration): We presented a case report of a 25 years old male with CKD stage 5 ec GN on Hemodialysis and secondary hypertension. He is on hemodialysis for the last 5 months. The etiology of the CKD is chronic GN, with comorbid hypertension in the last 4 years. He is first referred to Kandou in November 2021 with Nephrotic Syndrome, the symptopms were swelling on face, abdomen and legs, with foamy urine. The laboratory findings were massive proteinuria with urine dipstick + 4, hypoalbuminemia 1,7 gr/dl and hypertrygliceride 235 mg/dl and hypercholesterolemia with total cholesterol 748 mg/dl, decreased renal function with creatinine 1,9 and eGFR 50,2 ml/min/1,73m 2 . We examine abdominal ultrasound at that time and the kidney was normal in size, and can still differentiate medulla and cortex. He control regularly for 3 months until January 2022, with proteinuria still + 4, serum abumin 1,34 gr/dl, serum creatinine 2,3 mg/dl, with eGFR 23,3 ml/min/1,73m 2 . After that patient didn’t control until July 2023, he complain shortness of breath swelling almost all over the body, with laboratory findings ureum 357 mg/dl, serum creatinine 20,5 mg/dl, eGFR 2,9 ml/min/1,73m 2 . We perform abdominal ultrasound and we found the bilateral kidney is already contracted and can not differentiate the medulla and cortex, in accordance with description of chronic parenchymal renal disease. Then he underwent hemodialysis until now, twice per week. Kidney biopsy was not performed, even though on 2021 we already educate the patient to go to other nephrology center with renal histological capabilities. Method: Inpatient observation and investigation. Result (discussion): The cause of the CKD in this patient is GN. Although we couldn’t perform renal biopsy, the differential diagnosis are rapidly progressive glomerulonephritis, focal segmental glomerulosclerosis (FSGS) with nephrotic syndrome presentation, or other GN. At first, the patient only know the cause of his renal deterioration was caused by hypertension, but after we educate the main problem is the GN. Conclusion: We should be more aware patient with renal function disorder, especially younger patients, should dig deeper about our patient history, not easily think primary hypertension, and perform more renal biosy if necessary in the future.