Hypertension Renal

Question 1

What are the criteria for Hypertension?

Answer 1

Stage 1: Systolic: 140-159, Diastolic: 90-99

Stage2: Systolic: ≥ 160, Diastolic: ≥ 100

Question 2

How do you treat Stage 1 HTN vs Stage 2 HTN?

Answer 2

Stage 1: give one drug

Stage 2: give two drugs

Question 3

What are some risk factors for Primary (essential) Hypertension?

Answer 3

Age (70% of 70 yr olds have HTN)
Fam Hx
Race - African Americans
Decreased Nephron #
High sodium diet
booze
inactivity
Diabetes + dyslipidemia
personality traits/depression

Question 4

Why are African Americans predisposed to HTN? What can this lead to at an earlier age?

Answer 4

ApoL1 gene
-resists sleeping sickness from the tsetse fly but predisposes for HTN
progress to ESRD at a younger age

Question 5

What is Masked HTN

Answer 5

BP that is consistently elevated by out-of-office measures

-does not meet criteria for hypertension based upon office readings

Question 6

How common is HTN in the US?

Answer 6

29%-31% of adults in the US have hypertension

Question 7

How do Angiontensin II and Aldosterone alter BP

Answer 7

Angiotensin II - potent vasoconstrictor

Aldosterone - mad salt reabsorption

Question 8

What are some life changes that can prevent HTN?

Answer 8

1. WEIGHT REDUCTION
2. DASH eating plan (fruits, veggies)
3. Sodium reduction
4. physical activity
5. low booze drinking

Question 9

The dietary intake of what is associated with lowered BP?

Answer 9

Potassium, Magnesium, Fish oil, fiber, flavinoids, folic acid

dietary changes is equivalent to 1 medication

Question 10

What is the follow up time window for Normal BP, Prehypertension, Stage 1, Stage 2, >180 mmHg?

Answer 10

Normal: 2 years
Prehypertension: 1 year
Stage 1: confirm within 2 months
Stage 2: refer to care within 1 month
>180mmHg: evaluate immediately

Question 11

What are causes of Secondary HTN (hint: SCCORE)

Answer 11

Sleep apnea
Chemotherapeutic agents (VEGF inhib)
--reduces NO in the blood
Coarctation of Aorta
Oral contraceptives
Renovascular Hypertension, Renal disease
Endocrine - Cushings, pheo, hyperthy

Most common: Renovascular, Endocrine

Question 12

What are 4 reasons to work up patient for secondary hypertension?

Answer 12

1. severe/resistant HTN
2. pt w/ hx of controlled htn, becomes uncontrolled
3. <30yrs old, non obese, non black
4. Electrolyte abnormalities

Question 13

What are the 2 causes of High Renin + High Aldo

Answer 13

1. Renin Secreting Tumor (Increased renin = increased aldo)

2. Renal artery stenosis (renin, aldo try to increase perfusion)

Question 14

What causes Low Renin + High Aldo

Answer 14

primary hyperaldosteronism (high aldosterone suppresses renin)

Question 15

What are the 2 causes of Low Renin and low Aldo?

Answer 15

1. Liddles syndrome: hyperactive ENaC in principal cells = Salt retention suppresses renin/aldosterone by negative feedback
2. Cushings syndrome: Cortisol acts as aldosterone = salt retention

Question 16

What are 2 causes of Renovascular Hypertension and what demographic does this usually appear in?

Answer 16

Atherosclerosis
Fibromuscular Dysplasia

present in 10-45% of white patients with severe HTN

Question 17

What a suspicious signs of Renovascular HTN?

Answer 17

1. new onset HTN after 55
2. increase in creatinine w/ antihyptertensive therapy (does decrease in 6 weeks)
3. atherosclerosis in other organs
4. ATROPHIC kidney
5. abdominal bruit that localized to one side
6. recurrent pulmonary edema, HF

Question 18

What disease does Fibromuscular Disease appear with and what demographic (age, sex)

Answer 18

appears with renovascular hypertension (35-50% of CHILDREN, 5-10% adults)

more common in FEMALES (90%)

Question 19

What is the Imaging, and Tx of Fibromuscular Disease Renal Artery Stenosis

Answer 19

Imaging: Digital subtraction angiography
Tx: RAAS blocker (watch for creatinine, potassium increase)

Surgery (Revascularization)

Question 20

When should you treat with Revascularization?

Answer 20

Recent, Med resistant, Bilateral disease

in PVD: recurrent flash pulmonary edema, refractory HF

Question 21

When should you suspect Hyperaldosteronism as a cause of secondary HTN?

Answer 21

hypokalemia and metabolic alkalosis

Question 22

What are signs of Hypertensive Emergency and how do you treat?

Answer 22

>180/120 mmHg WITH target organ damage
LVH, CHD, HF
RETINOPATHY
TIA, stroke
Renal failure
PVD

Lower blood pressure slowly (if lowered too fast pt can present with symptoms of stroken b/c elevated BP was used to perfuse parts of the brain)

Question 23

When should you suspect Hypertensive Nephrosclerosis?

Answer 23

Long Hx of HTN
BLAND URINE SEDIMENT
no other etiology of renal disease
RENAL BX: sclerosis, hyaline