Nephrology Flashcards
What are the BP thresholds for diagnosing hypertension with the various BP measurement methods
AOBP: 135/85, 130/80 in DM
Non-AOBP: 140/90, 130/80 in DM
24hrs ambulatory: 135/85 daytime, 130/80 (24hrs)
Home BP: 135/85
BP cuff measurements
width 40% of arm circumference
length 80-100% of arm circumference
What are the thresholds to diagnose HTN in non-diabetics when no ambulatory BP measurements are available
Visit 2: >140/80 WITH macrovascular disease, CKD, T2DM
Visit 3: Mean BP >160/100
Visit 5: Mean BP > 140/90
What investigations should be done at diagnosis for hypertension
LBC, Fasting glucose and/or A1C, lipid profile, UA
ACR if diabetic, renal disease, or proteinuria on UA
ECG if suspicion for LVH, systolic or diastolic dysfunction, or CAD
Who should be screened for renovascular HTN
2 or more of the following:
- Sudden onset or worsening HTN, age>55 or <30
- Abdominal bruit
- HTN resistant to 3 drugs
- Creatnine increase of >30% on ACEi or ARB
- Other atherosclerotic vascular diseases, Particularily in smokers or DLP
- Recurrent pulmonary edema associated with HTN surges
What is the screening test for Renovascular hypertension (4 possible)
Doppler
Captopril renogram
MRA
CTA
Who should be worked up for FMD related Renal artery stenosis
- Asymmetric kidneys (>1.5 cm difference)
- Abdominal bruit with no atherosclerotic risk factors
- Confirmed FMD in another vascular bed
- Family Hx of FMD
How do you work up FMD
CTA or MRA
When confirmed, screen vasculature from head to pelvis with CTA or MRA
What are the SPRINT inclusion criteria
SBP > 130, age >50 and 1 or more of:
- Clinical or subclinical CVD
- CKD: eGFR 20-59, proteinuria <1g/day – non diabetics
- 10 year CV risk > 15%
- Age > 75
What are the SPRINT exclusion criteria
- DM
- Previous stroke
- GFR <20
- Proteinuria > 1g/day
- PKD
- Contraindications:
- Non-adherence
- Standing SBP<110
- secondary HTN
- Can’t measure BP accurately
- life-limiting illness
What are the non-pharmacological interventions used in HTN
- Exercise: 30-60 min. Moderate intensity, dynamic, 4-7 days per week
- Weight: BMI 18.5-24.9 Waist circumference <102(M) <88 (F)
- Alcohol: Abstain OR reduce to <2drinks per day (prevention) and if >6 drinks a day, reducing to <2 can reduce BP
- Diet: DASH diet, Increase K intake if not high risk for hyperkalemia
- Salt: <5g/day Na
- Stress reduction: inc CBT and relaxation techniques
- Smoking cessation
What are the BP treatment targets
SPRINT: SBP<120
DM: <130/80
Low risk: <140/90
For CKD patients, individualize. If PKD target <110*
(HTN Canada)
What are the 1st and 2nd line BP med options in diabetes?
1st line:
IF CV disease. or risk factors, CKD/microalbuminuria:
Use ACEi or ARB
if not:
ACEi, ARB, DHP CCB, thiazide
2nd line (with 1st line ace): DHP-CCB
Possibly consider SGLT2
Indications to CONSIDER stenting in RAS
- Uncontrolled HTN resistant to maximally tolerated pharmacotherapy
- Progressive renal function decline
- Acute pulmonary edema
Firstline antihypertensives for isolated systolic hypertension
- Thiazide
- Long acting DHP-CCB
- ARB
Firstline antihypertensive for diastolic hypertension
- Thiazide
- BB if <60
- ACE/ARB
- Long acting DHP-CCB
Firstline antihypertensives for LVH
- Thiazide
- ACE/ARB
- Long-acting DHP-CCB
*Do not use vasodilators
**Avoid BB
Firstiline antihypertensive for non-diabetic with CKD and proteinuria
ACE/ARB
*Additive Tx: Thiazide
**If vol overload, can use Lasix instead of ACE
Firstline antihypertensive in CAD
- ACE/ARB
Then can add CCB or BB
ACE + CCB over ACE+thiazide
Firstline antihypertensive in stable CAD
BB or CCB
Firstline antihypertensive in recent MI
BB+ACE
Firstline antihypertensive in EF<40%
ACE + BB
ARB in intolerante to ACE
Hydralazine + ISDN if can’t use ACE/ARB
Second-line antihypertensive in EF<40%
MRA
Treatment of anti-GBM
- Pulse steroids (6 months)
- Cyclophosphamide (2-3 months)
- PLEX (until titers no-longer detectible, usually 14 exchanges)











