16: Renal disease, HTN, and renal a. stenosis - Thompson

Question 1

what might happen when kidneys fail?

Answer 1

• • Electrolyte imbalances (phos gets high, potassium high, calcium low)
• -Anemia
• • Blood pressure irregularities
• • Meds hang around

Question 2

renal disease ________ HTN

Answer 2

goes both ways - both can lead to each other

Question 3

normal Cr

Answer 3

.6-1.2

dialysis level — 5!

Question 4

JNC8 Recommendations for BP **

Answer 4

greater than 60
150/90

less than 60
140/90

greater than 18 with CKD
140/90

greater than 18 with DM
140/90

Question 5

risk factors for HTN

Answer 5

Age
Smoking
DM
High lipids
Inactivity/weight
Family history
Race

Question 6

secondary causes HTN

Answer 6

• Sleep apnea
• Primary hyperaldosteronism (low K, htn resistant)
• CRF
• Thyroid
• Renal vascular disease
• Pheochromocytoma
• Cushings or steroid therapy

Question 7

Diagnose with a high aldosterone/renin ratio – their K will often be low

Answer 7

Primary Hyperaldosteronism

Consider in patients with resistant hypertension and a low potassium

Question 8

basic work up for HTN

Answer 8

EKG
UA
BMP
TSH
H&H
Ca
Cholesterol

Question 9

problems with beta blockers

Answer 9

Dizzy/syncope
Fatigue
Low HR
Impotence
Makes working out difficult

Question 10

use for ACE inhibitors

Answer 10

Used in DM (regardless of BP) CHF and post MI – many beneficial effects

• • Decreases all CV causes of death in DM II
• • Think increases flexibility of vessels
• • Causes cardiac remodeling (repair)

Question 11

side effects of ACEi

Answer 11

– Increases K
– Angioedema (.2%)
Asians/Blacks 3-4X more likely
– Cough
> 8%
– Increase Cr
Can increase 30% before stop or big w/u
Small increase means intraglomular pressure has been reduced

Question 12

inhibits NaCl reabsorption

Answer 12

Thiazides

• • K/Na reduction
• • Renal damage
• • Increased glu, Ca

Question 13

JNC8 recommendations for nonblack v. black population

Answer 13

nonblack: thiazides, CCB, ACEi, or ARB
black: thiazide or CCB

Question 14

tx CKD

Answer 14

include ACEi or ARB

Question 15

up-titrate or add therapy after ________ if BP goal not achieved

Answer 15

1 mo

don’t use ACEi and ARB together
if greater than 3 dugs needed, refer to HTN specialist

Question 16

if _____ to start, just start 2 meds

Answer 16

greater than 160/100

Question 17

take aways

Answer 17

• • Beta Blockers are NOT first line (unless post MI)
• • Whites – start almost anything else (Thiazides, ACE/ARB, CCB)
• – Blacks – avoid ACE (why)
• • Diabetics/CRF – ACE
• • Post MI/CVA – beta blocker/ACE
• • CHF – Beta Blocker + ACE, plus thiazide plus spiranolactone

Question 18

Any increase in BP that results in acute end organ damage

Answer 18

malignant hypertension

still want to lower the BP slowly

Question 19

> 180 or >110

No symptoms or vague symptoms

Answer 19

Hypertensive urgency

Question 20

mechanism of renal a. stenosis

Answer 20

When renal arteries are constricted to the point that the kidneys have a decreased blood flow.

Kidney thinks body is hypovolemic and secretes renin which increases BP

Question 21

Doesn’t respond to treatment  
Intermittent claudication
Sudden worsening of htn
Image abnormality
ACE leads to worsening creatinine

Answer 21

suspect RAS

caused by atherosclerosis older of fibromuscular dysplasia (younger)

risk factors are:
HTN
Obesity
Vascular disease of any kind
Age
Smoking

Question 22

what happen to kidneys if BP uncontrolled?

Answer 22

Affected kidney gets small, ischemic
Ischemic nephropathy

Other kidney gets injured from the increased BP
Hypertensive nephrosclerosis

Question 23

describe fibromuscular dysplasia

“string of pearls on imaging”

Answer 23

Angiopathy of medium sized vessels; mainly seen in women of childbearing age.
Seems to increase just before menopause
Genetic link as well
Symptoms occur where artery occluded (brain, periphery – kidneys mainly)
Rare – less than 1% of population