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Zorluk: ZorDiagnostic Workup and Test Sequencing

A 68-year-old man comes to the clinic for a follow-up examination for difficult-to-control hypertension. He was diagnosed with hypertension 15 years ago. For the past year, his blood pressure has been consistently greater than 160/100 mm Hg despite documented adherence to maximum tolerated doses of amlodipine, metoprolol, and chlorthalidone. One week ago, his physician added lisinopril to his regimen. His medical history is also significant for type 2 diabetes mellitus, hyperlipidemia, and peripheral artery disease characterized by bilateral calf claudication. Today, his blood pressure is 178/98 mm Hg and heart rate is 72/min. Physical examination reveals diminished pulses in the lower extremities and a right-sided abdominal bruit. Laboratory studies from two weeks ago showed a serum creatinine of 1.1 mg/dL. Today, his serum creatinine is 1.9 mg/dL and serum potassium is 4.8 mEq/L. Which of the following is the most appropriate next step in the diagnostic workup?

  1. Renal duplex ultrasonographyCevap
  2. B
    Computed tomography (CT) angiography of the renal arteries
  3. C
    Selective renal catheter angiography
  4. D
    Plasma aldosterone concentration to plasma renin activity ratio
  5. E
    Captopril-enhanced radionuclide renal scan

Cevap

Renal duplex ultrasonography
Renal duplex ultrasonography is a non-invasive, inexpensive initial screening test for renal artery stenosis that does not require the administration of potentially nephrotoxic intravenous contrast. In a patient with an acute kidney injury (evidenced by a serum creatinine jump from 1.1 to 1.9 mg/dL after starting lisinopril), it is the safest and most appropriate first step to confirm the suspected diagnosis of renovascular hypertension.

Adım Adım Çözüm

1
Analyze the patient's clinical presentation.
The patient has resistant hypertension, widespread atherosclerosis (peripheral artery disease), an abdominal bruit, and an acute increase in serum creatinine (>30%) following the initiation of an ACE inhibitor.
These findings are classic for renovascular hypertension secondary to bilateral renal artery stenosis (or stenosis in a solitary kidney).
2
Determine the need for diagnostic imaging.
Imaging is indicated to confirm the anatomical diagnosis of renal artery stenosis.
Confirming the lesion guides further medical management or potential revascularization.
3
Select the most appropriate initial imaging modality based on the patient's comorbidities.
Renal duplex ultrasonography is chosen as the initial test.
The patient's acute kidney injury precludes the use of iodinated contrast (used in CT angiography) and gadolinium (used in MR angiography, particularly if GFR drops lower). Ultrasonography is safe, non-invasive, and effective for initial screening.

Anahtar Kavram

The initial diagnostic evaluation of suspected renal artery stenosis in a patient with acute kidney injury requires prioritizing safe, non-contrast imaging modalities.
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Diagnostic Workup and Test Sequencing

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