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CT abdomen/pelvis
2%
1/44
Increase dose of current blood pressure medications
9%
4/44
Lisinopril
52%
23/44
Renal ultrasound with Doppler
23%
10/44
Surgical revascularization
Select Answer to see Preferred Response
This patient is presenting with an abdominal bruit, refractory hypertension, and vascular risk factors, most concerning for bilateral renal artery stenosis. The best initial step in management is renal ultrasound with Doppler. In renal artery stenosis, there is decreased blood flow to the juxtaglomerular apparatus causing activation of the renin-angiotensin-aldosterone system and subsequent hypertension (as well as hypokalemia and a metabolic alkalosis). Renal artery stenosis is the most common cause of secondary hypertension. Underlying causes include atherosclerosis (more common in elderly men) and fibromuscular dysplasia (usually seen in young women). Key presenting findings include hypertension (but no family history of hypertension) and blood pressure which is resistant to medical therapy. The best initial step in management is a renal ultrasound with Doppler. Confirmation can be done with magnetic resonance angiography, a nuclear renogram, or a renal angiogram (the most accurate test). Possible treatments include revascularization with percutaneous transluminal renal angioplasty, bypass surgery, or conservative medical therapy. ACE inhibitors can be given if there is unilateral disease but should not be used in patients with bilateral renal artery stenosis as they may precipitate acute renal failure. Incorrect Answers: Answer 1: CT abdomen/pelvis would characterize the kidneys for conditions such as adult polycystic kidney disease (hypertension, hematuria, and kidney failure in a middle aged adult) or could identify a stone in nephrolithiasis (colickly flank pain radiating to the groin with hematuria). It would not characterize the blood flow in renal artery stenosis which is needed to make the diagnosis. Answer 2: Increase dose of current blood pressure medications would be appropriate if this patient was merely sub-optimally managed without another etiology for his hypertension. Prior to increasing the dose of other drugs, other organic etiologies of his hypertension should be ruled out such as this patient's abdominal bruit and possible renal artery stenosis. Answer 3: Lisinopril is an ACE inhibitor which is contraindicated in patients with bilateral disease since they may precipitate acute renal failure. If the patient had unilateral disease and was not a surgical candidate, then it could be appropriate. Answer 5: Surgical revascularization could be indicated after the diagnosis is supported with a ultrasound with Doppler and perhaps confirmed with CT angiography. Surgical treatment would not be performed until the diagnosis is confirmed. Bullet Summary: The best initial step in management in renal artery stenosis is an ultrasound with Doppler.
4.6
(11)
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