Hypertension is a common condition that results in outcomes such as stroke and death. As of 2015, hypertension was the cause of a whooping 75,000 deaths in the United Kingdom alone.¹ WHO also records hypertension as a significant cause of premature deaths in 2013.² They further recorded 1 in 5 individuals having uncontrolled hypertension.²

Hypertension is a widespread complication in many kidney conditions. Unlike hypertension, fibrillary glomerulonephritis is a rare condition.³ Fibrillary glomerulonephritis is seen in 0.5-1.4% of most kidney biopsies.³ It affects 50-60% of the Caucasian population.³ Despite their contrasting incidences, these two conditions often occur together. This occurrence is often a recipe for disaster, as both conditions have an overwhelming effect on the kidneys.

Living with hypertension on its own can be tasking. Imagine living with it as a by-product of a condition. It is often easier to avoid a condition when the cause is specific. Hypertension has no single cause, and it is a common occurrence in fibrillary glomerulonephritis. Patients who develop hypertension in fibrillary glomerulonephritis face many constraints. These constraints manifest in their day-to-day physical activity or mental well-being. 

Definition

What is Hypertension?

Hypertension is a condition that occurs due to rising pressure within the blood vessels of 140/80mmhg or higher. A sphygmomanometer, which could be electronic or manual, determines this pressure. Once the sphygmomanometer detects two high blood pressure readings on two different days, the diagnosis of hypertension comes into play. 

Several factors come into play in hypertension, as one factor may not put one at risk. They are:

• Age 
• Family history 
• Lifestyle choices such as
  • Diet: Processed and salty food 
  • High Alcohol intake 
  • Sedentary lifestyle 
  • Obesity 

Although hypertension can be asymptomatic, it can present with symptoms like: 

• Profuse sweating 
• Chest pain
• Dizziness
• Nausea
• Blurred vision 

What is Glomerulonephritis?

The syndrome ‘glomerulonephritis’ results from the immune system's reaction to itself. The body sticks a knife in its kidney structures. This action results in damage to the following: 

• Basement Membrane 
• Mesangium 
• Capillary endothelium 

In the end, the damage causes devastating results, such as:

• Hematuria
• Proteinuria
• Azotemia 

What is Fibrillary Glomerulonephritis (FGN)?

First described in 1977, fibrillary glomerulonephritis is a rare kidney condition that affects the glomeruli's ability to filter proteins. Despite its similarities with glomerulonephritis, there is a clear difference. In fibrillary glomerulonephritis, fibrils accumulate in the glomerulus. These fibrils look like amyloids but are larger. For a positive confirmation, these fibrils are IGG positive and congo red negative. 

What are the risk factors of Fibrillary Glomerulonephritis?

They are the following:

• Age: 10-89
• Causcian descent 
• Immunocompromised Patients
• Hepatitis C 
• Other conditions that cause activation of the immune system 

Etiology

How does hypertension develop in Fibrillary Glomerulonephritis patients?

These key points are crucial for understanding how hypertension develops in this condition.

• Fibrillary glomerulonephritis is a type of glomerulonephritis, so they have similarities
• The immune system's attack on itself causes both conditions
• In fibrillary glomerulonephritis, white blood cells are the culprit attacking the glomerulus
• These attacks are due to the antigens that Group A Beta haemolytic streptococcus produces
• The result is first scarring and thickening of the glomerulus, followed by a decline in the glomerular filtration rate (GFR)

With that said, let's move on to how hypertension is a tenant here. The kidneys have several key players in the management of hypertension. The glomerular filtration rate is one of those players. Hence, when there is a decline, there will be 

• Increased sodium reabsorption
• Activation of the renin-angiotensin system 
• Efferent arterioles resistance 

In the end, glomerular hypertension sets in. 

Diagnose

Diagnosis of hypertension in fibrillary glomerulonephritis doesn't have a particular pathway. Due to the progression of the disease, your physician will always suspect hypertension. Hence, your physician will need you to take regular blood pressure readings. They will confirm the diagnosis if you have two readings of 140/80mmhg or above on two different days.

Sypmtoms

A decline in GFR is a massive factor in the poor outcomes of FGN patients. Hypertension doesn't help— it spells double trouble when brought into the mix. Fibrillary glomerulonephritis and hypertension both have a massive impact on GFR. 

The difference is that FGN causes the immune system to damage the glomerulus. But, hypertension deprives the blood vessels of necessary nutrients and oxygen. Hypertension leads to complications that affect FGN’s patients’ quality of life. One such complication is End-Stage Kidney Disease (EKSD). 

It affects the patient's quality of life in two ways :

• Through the symptoms, they will experience
• Possible constraining outcomes

Symptoms like fatigue and oedema at the extremities will impact their daily routine. Also, a potential outcome of lifelong use of hemodialysis, as seen in the (3) case study, has an impact.

Management

General management 

General management of fibrillary glomerulonephritis patients usually involves two pathways. These pathways include: 

Monitoring your blood pressure 

A physician requires a hypertensive patient to check their blood pressure regularly. This routine doesn't fall into the sand with fibrillary glomerulonephritis patients. The reason why they will ask you to do this with preference to morning readings is because:

• To get baseline data
• To understand the progress your hypertensive drugs are making

Lifestyle modifications

Management of hypertension involves the change of certain lifestyles that are unhealthy. These lifestyles can worsen an alreadly bad condition, so you're better off avoiding them. Some of them include:

• High alcohol intake
• High salt intake 
• Sedentary lifestyle
• Smoking 
• Chronic stress
• Consumption of vast amounts of processed foods 

Use of medicine 

Once the physician diagnoses you, they put you on a combination of drugs ⁴. These drugs help reduce both blood pressure and its associated symptoms. WHO recommends these medications as the first-line therapy for hypertension:⁴

Diuretics

This drug aims to reduce the amount of water stored in your body. Diuretics are essential because this water stored causes pitting oedema of varying degrees. WHO recommends thiazides or thiazide-like drugs as a first response.⁴ 

Angiotensin Converting Enzyme Inhibitors (ACEIs) or Angiotensin Receptors Blockers (ARB):

Both these drugs do the same thing. Hence, the two drugs are not given to patients together. The physician chooses which drug best suits the patient based on the following:

• Patient Tolerance to ACEIs: If there is any reaction, the physician gives ARBs
• Condition Type: Physicians prefer to give ACEIs in heart failure⁵
• Medical History: A history of angioedema due to ACEIs is a sign for ARBs 
• Race: ACEis are safer in Caucasians, unlike in those of African and Chinese descent. This trend is because of side effects like angioedema and severe cough that occur, respectively. Also, ARB tends to be more effective in those of African descent⁶

Although you can use either for FGN, the physician must consider these criteria first. Regardless, both will help the GFR and proteinuria present. 

Calcium channel blockers 

WHO guidelines recommend the use of long-acting dihydropyridine calcium channel blockers. These blockers help relax the blood vessels. They do this by inhibiting calcium from entering the heart and blood vessels. 

Summary 

Fibrillary glomerulonephritis is a rare condition that presents with hypertension, hematuria and proteinuria. Hypertension in this condition results from damage to the glomerulus. This damage affects the GFR and in the end affects the quality of life of its patients. Their quality of life is affected because of the following:

• They will be subject to lifestyle modifications 
• Hypertension worsens the condition 
• A potential outcome like a life dependent on hemodialysis is possible

Drugs and lifestyle modifications are uncomfortable. Despite this, there are essential factors that help control:

• blood pressure
• proteinuria, and
• GFR

Thus, it is necessary to take them seriously, as they could prevent death. Hypertension is one of the main actors in FGN, but it has its research limitations. There are few works about hypertension in FGN. Despite this, The medical community will make advancements as FGN was once considered idiopathic. Today, we have research telling us about 

• FGN in general
• Its mechanism of action 
• Its treatment and
• Its risk factors