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Demo Question

A 52-year-old individual presents to the clinic with complaints of persistent headache and episodes of dizziness for the past 3 months. The patient also mentions occasional episodes of visual disturbances. On further questioning, the individual reports a family history of hypertension and chronic kidney disease. They have a BMI of 35 and take a statin for hyperlipidaemia. On examination, there is evidence of pitting oedema to the knees. The patient's blood pressure reading consistently reveals values greater than 160/90 mmHg on multiple occasions. Labs show an elevation in serum creatinine and a decreased estimated glomerular filtration rate (eGFR).

Based on the findings and the patient's history, which of the following is the most likely cause of the patient's symptoms?

  Primary essential hypertension
  Renovascular disease
  Diabetic nephropathy
  Glomerulonephritis
  Polycystic kidney disease

Key learning points

Hypertension can result in renal stenosis, commonly caused by atherosclerosis or fibromuscular dysplasia. The symptoms associated with this condition are notably resistant hypertension and an unexpected drop in kidney function.

Explanation

The patient presents with accelerated likely undiagnosed hypertension symptoms associated with a decreased eGFR and other clinical manifestations such as headache and visual disturbances. The family history of hypertension and kidney disease also suggests a possible renovascular component, as does the raised BMI,  making this the most likely diagnosis. Renovascular hypertension results from compromised renal blood flow, often due to atherosclerotic disease or fibromuscular dysplasia.

Hypertension can result in renal stenosis, commonly caused by atherosclerosis or fibromuscular dysplasia. The symptoms associated with this condition are notably resistant hypertension, risk factors for atherosclerotic disease such as obesity and an unexpected drop in kidney function. Renal imaging may show narrowed renal arteries, and certain clinical signs like decreased peripheral pulses, bruits, or differences in kidney size.

A comprehensive history and examination should include:

  • Checking for a high-risk medical history.
  • Inquiring about family history related to hypertension or kidney disorders.
  • Looking for features like sudden hypertension onset, severe or resistant hypertension, and inconsistencies in kidney size on ultrasound.
  • Checking for risk factors like smoking, obesity, age, atherosclerosis, and others.

For diagnostic assessment:

  • Primary tests include renal Doppler ultrasound and  renography.
  • Secondary tests include CT angiography and MRI.


Primary essential hypertension is a common cause of elevated blood pressure, but it typically does not result in kidney disease symptoms or a rapid decrease in eGFR quite so dramatic as this.

Diabetic nephropathy presents in patients with a long-standing history of diabetes. The patient in the vignette does not report a history of diabetes.

Glomerulonephritis is the cause of kidney disease and hypertension but is typically associated with other symptoms such as hematuria, proteinuria, and sometimes an active urinary sediment. The vignette does not provide evidence for this or any other cause for glomerulonephritis.

Polycystic kidney disease is a genetic disorder which can result in hypertension and kidney disease, the presentation would also often include multiple cysts on renal imaging and a family history specifically of PKD.

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