PANCE Blueprint Renal System (5%)

Renal vascular disease

Patient will present as → a 69-year-old man with a 55-pack-year smoking history, diabetes type II, and hyperlipidemia presents to his primary care clinic for an annual exam. He has no complaints. He reports that his blood glucose has been under tight control and that he has not smoked a cigarette for the past 5 months. Vital signs are HR 69 bpm, BP 180/100 mmHg, RR 12/min, and O2 saturation 99% on room air. Physical examination is notable for bruits bilaterally just lateral of midline near his umbilicus. You initiate an anti-hypertensive medication, but his blood pressure continues to be suboptimal. Creatinine is 3.5.

Renal artery bruit (with bowel sounds)

What type of antihypertensive medication is contraindicated in patients with renal artery stenosis?
ACE inhibitors (result in renal insufficiency)

Renal artery stenosis is the narrowing of one or both of the renal arteries, most often caused by atherosclerosis or fibromuscular dysplasia.

  • This narrowing of the renal artery can impede blood flow to the target kidney, resulting in renovascular hypertension – a secondary type of high blood pressure.

May hear a renal artery bruit on auscultation

  • Patient may present with HTN before age 30, HTN with CAD or PVD history, Hypertension resistant to three or more drugs
  • If patient is placed on an ACE inhibitor and all of a sudden develops acute renal failure or sharp rise in BUN/CR you should think renal artery stenosis

Ultrasound: often initial imaging in those < 60 years of age in patients with suspected RAS

  • Renal arteriography is GOLD STANDARD for diagnosis

Stenting of renal arteries

  • Treatment is with percutaneous transluminal angioplasty (PTA) plus stent placement or with surgical bypass of the stenotic segment. Usually, an extensively infarcted kidney must be removed if revascularization is not expected to result in functional recovery.

Question 1
A 51 year-old male with renal artery stenosis and an elevated BUN and creatinine, is newly diagnosed as hypertensive. Which of the following agents should be avoided?
A
hydrochlorothiazide-triamterene
B
prazosin
C
nifedipine
D
verapamil
E
furosemide
Question 1 Explanation: 
This is a potassium sparing diuretic and should be avoided in anyone with renal disease. ACEI should be avoided as well (but none of these are ACEI's)
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Polycystic kidney disease (Lecture) (Prev Lesson)
(Next Lesson) End Stage Renal Disease (ESRD)
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