Monday, March 19, 2018

Renal Causes of Hypertension : A Summary

Hypertension in a young individual needs specific evaluation to rule out Non Essential Hypertension (Secondary Hypertension). The Most Common cause of this is Renal Hypertension.

Renal causes of Hypertension can be summarized as follows  -
A. Reno-vascular ( Atherosclerotic/ Fibromuscular Dysplasia - FMD)
(Uncommon = Vasculitis , AV Malformation)
B. Parenchymal Renal Diseases like Glomerulonephritis.

Typical Presentations :
FMD =
- A young 20-30 year old female , with Hypertension and possibly asymmetrical pressures in both limbs, and associated with a Renal Artery bruit.

- Typically have history of some form of Cranial vessel involvement in the form of Strokes in a Young Female , TIA's , other transient neurological phenomena.

- Carotidynia may be + (Due to carotid dissection).

- Ix =  Rule out Atherosclerosis;
Angiography -  String of beads appearance.

- Rx = Anti Platelets , Anti HT .
May need Endovascular clot treatment.
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GN
- A 10-25 year old male or female with cola colored urine , fever and periorbital puffiness. Older adults may have more atypical features like Hypertensive Encephalopathy and may develop Uremia.

- H/O antecedent Streptococcal infection - 3-4 weeks prior.

- Ix - Urine report shows Hematuria, RBC Casts and Nephritic range proteinuria.
Renal profile and Urine output to be done and monitored regularly.
Get ASO titers for previous strep infection.

- Rx - Symptomatic. IV fluids.
May need Renal Replacement if Uremia sets in.
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In Addition to routine , the extra Investigations to rule out Renal cause in a young patient with Hypertension -

1. Urine Routine and Microscopy
( Look for Hematuria,  RBC Casts, dysmorphic RBCs )

2. Renal Function Testing -
( Look for rise in S. Creatinine, BUN and electrolyte imbalances)
(Also gives a clue to the Adrenal cause of Hypertension with Sodium and Potassium changes).

3. Imaging -
• Pelvic Ultrasound for any structural abnormality of urological tract - due to Congneital or Acquired causes.
• Angiography (Digital Subtraction Angiography) - to look for renal artery stenosis. (Always with a pre procedure creatinine)
• MRI if needed. 

4. Serology -
• ASO Titres
• Anti DNAse B Ab's ( not done commonly)
• Complement levels - may be reduced.
• Antibody panel for various Vasculitis - ANCA , ANA and AMA.

5. Lipid profile for Atherosclerotic vascular disease. 

That's all for this post !
Hope this helps - both on the wards and the boards.
Happy Studying!
Stay Awesome !
~ A.P. Burkholderia

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