By: Medical Students: Jake Ziegler, Kevin Piper, Sandi Riggs, Mark Vukonich,

Sara OlmansonPharmacy Students: Abby Johnstone, TJ Gagne

“Dr. Johns sent me for a consultation. My blood pressure is too high.”

• 68 year-old female with HTN for 20 years • Past 6 months: more difficult to control with

readings in the 150/100 range • She has taken hydrochlorothiazide 50 mg daily and

amlodipine 5 mg daily for years with good control• Overall has felt fine but some morning headaches. • Watches her salt carefully and tries to walk for

exercise three times a week.• Her physician placed her on enalapril 10 mg per

day 2 weeks ago when he noted a blood pressure of 170/110. 

• Lab obtained that day included a normal urinalysis, normal potassium and creatinine of 1.5.

• Operations:– Cholecystectomy – 1998– Appendectomy – 1980

• Hospitalization for unstable angina one year ago. Had angioplasty and stent of LAD

• Adult Illnesses:– HTN as mentioned above– Hyperlipidemia for 10 years– Osteoarthritis of left knee for 2 years, treated

with ibuprofen and occasional cortisone injections.

Enalapril 10 mg per dayMechanism: ACE inhibitor Uses: HTN, CHF, LVD SE:  decrease BP with initial dose (especially

with concomitant diuretics),  increase K+, nonproductive cough, angioedema

Doses: 2.5–40 mg/d PO Notes: Monitor Cr

Hydrochlorothiazide (50 mg daily)Mechanism:  decrease distal tubule Na

reabsorption Uses: HTN and edemaSE:  decrease K+, hyperglycemia,

hyperuricemia,  decrease Na+

Notes: May cause sun sensitivity Dosing: 25–100 mg/d

Amlodipine (5 mg daily) Mechanism: Calcium Channel BlockerUses: HTN and Unstable AnginaSE:  Peripheral edema, HA, palpitations,

flushing Dosing :2.5-10 mg/day

Atorvastatin (Lipitor) (40 mg each evening)Mechanism:  HMG-CoA reductase InhibitorUses: hyper - cholesterol & triglycerides SE: Myopathy, HA, arthralgia, myalgia, GI

upset Dosing: Initial 10 mg/d, may increase to 80

mg/d Notes: Monitor LFTs

Ibuprofen (400 mg three times daily)Aspirin (325 mg daily) – seems high

Allergies: None

Smoking:1 ppd for 30 years, quit one year ago

Alcohol: OccasionalFamily History: Brother has mild

hypertension.Social History: Married, lives in rural St.

Louis County, own well and septic. Likes to garden.

Occupational History: Retired high school math teacher

Overall feels well.No chest discomforts with exertionNo cough or shortness of breathHas noted some muscle cramping in legs

for past couple months after 3 blocks of walking, slows her some.

No dysuria

• General: A pleasant female in no acute distress

• Height : 64 inches• Weight: 160 lbs.• Vitals:

– Blood Pressure: 170/100 both arms– Heart Rate: 70 reg– Respiration Rate: 12 – O2 sats = 96% on RA

• HEENT: PERRL, A-V nicking and mild arteriolar narrowing on fundus exam

• Neck: supple, faint right carotid bruit, normal thyroid palpated

• Chest: normal A-P diameter; lungs are clear to auscultation and percussion

• Heart: S1 and S2 are normal, no gallop or murmurs• Abdomen: soft, non-tender, good bowel sounds, no

masses noted. Bruits over femoral arteries bilaterally.

• G-U:Musculo-skeletal: normal exam• Skin: no rash noted• Neurological: no lateralizing neuro findings• Extremities: intact pulses w/o edema

Primary HTN – idiopathicNephrotic Syndrome Goodpasture Syndrome -SandyHyperthyroidism (check on hypo) - SandyGlomerulonephritis - JakeHeavy Metal Poisoning – JakeSecondary HTN

Pheochromocytoma - KevinPrimary Aldosteronism -KevinCushing Syndrome - KevinRenal Artery Stenosis - Mark

AtheroscleroticFirbromusculardyplasia of renal artery

NSAID Induced Renal Failure

BP

ClassificationSBP

(mm HG)DBP

(mm HG)

Normal <120 and <80

Prehypertension 120-139 or 80-89

Stage 1 hypertension

140-159 or 90-99

Stage 2 hypertension

160 or 100

National Heart, Lung, and Blood Institute. JNC 7 Express. The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure. 2003.

Essential hypertension indicates that no specific medical cause can be found to explain a patient's condition.

Diagnosis of Exclusion

Heavy Proteinuria, > 3.5 grams/dayHypoalbuminemia, serum albumin < 3 gr/dlHyperlipidemiaLipiduriaEdema, presence of excess fluid in the

interstitial space due to inability to excrete a salt load

Urinalysis, urine total protein/creat ratio.Renal function and serum albumin, lipidsHep B, Hep C, HIVFANA, ANCA, C3, C4,AntiGBM AbySerum and Urine ImmunoelectrophoresisKidney Biopsy

Urine – normal, $40Creatinine - serum: 3.7 mg/dl $20

Her Creatinine was 1.5 mg/dl.GFR has since decreased

Appearance: normal  Color: Yellow/clear Bile: 0  Glucose: 0 mg/dL Ketones: 0  Leuko Esterase: 0  Misc: normal  Nitrite: 0  pH: 7.46218595799  Protein: 0 mg/dl Specific Gravity: 1.01395264938  Urine Collection Type: normal  Urobilinogen: 0.569220773136 

HDL-female: 53.8Normal: Female: 39-96 mg/dl

LDL: 117.7 mg/dlPhospholipids: 11.6 mg/dl as lipid phosphorusTotal Cholesterol: 196.4 mg/dlTotal fatty acids: 215.1 mg/dlTotal lipids: 839.3 mg/dlTriglycerides: 33.5 mg/dl$82

Albumin: 4.4 g/dl Alk phosphatase: 96.7 IU/l ALT (SGPT): 15.4 IU/l Amylase: 76.3 U/l AST (SGOT): 24.3IU/l BUN: 11.7 mg/dl Calcium: 8.7 mg/dl (corrected calcium = 8.2 = little low) Direct bilirubin: 0.087mg/dl GGT: 14.2 IU/l Glucose: 87.7mg/dl Lactic dehydrogenase (LDH): 83.4 IU/l Phosphorus: 2.9 mg/dl Protein, Total: 7.2 g/dl Total bilirubin: 0.76 mg/dl

Carbon Dioxide (CO2): 31.4 mEq/lNormal 35-40

Chloride: 109.8 mEq/l95-105

HCO3 (Bicarbonate): 23.9 mEq/l22-26

Potassium: 3.6 mEq/l3.5-5

Sodium: 137.9 mEq/l135-145

Not the diagnosisNo proteinuriaNo hyperlipidemia (under control)No hypoalbuminemia

Her Creatinine has gone from 1.5-3.7gm/d in two weeks.

AKA anti-glomerular basement membrane disease

Autoimmune disease attacking lungs and kidneys

Affects glomerulous blood in urine, renal failure

ANAAntinuclear antibodies (ANA): 32 titerNormal 1-40 titer$76

Sx: HTN, loss of appetite, edema, hemoptysis, chills, fever, N/V, chest pain, anemia, arthalgias

PE: tachypnea, inspiratory crackles, cyanosis, hepatosplenomegaly, rash

Patient’s Sx and PE not consistant with Goodpasture

“Overactive thyroid” increased levels of T3 and T4, low TSH

Sx: Palpitations, increased appetite, heat intolerance, restlessness, insomnia, increased bowel movements, fatigue

PE: HTN, tachycardia, trembling hands, weight loss, muscle weakness, warm moist skin, hair loss, goiter

Labs: TSH is within normal limits [0.5-5] (if hyperthyroidism, it would be less than 0.5).

Thyroid stimulating hormone (TSH): 2.5 m IU/m

$58

Nephritic SyndromeHematuriaMild to moderate proteinuriaHypertensionClassic: Post-streptococcal glomerulonephritis

Nephrotic Syndrome>3.5gm/day proteinuriaHypoalbuminemiaHyperlipidemiaEdemaLipiduria

Certain strains of Group A beta hemolytic streptococci are nephritogenic

Occurs 1 – 4 weeks post a pharyngeal or skin infectionAffects all ages but more common in childrenClinical presentation: Nephritic

Malaise, fever, oliguria, hematuria (“smoky urine”)Red cell casts, mild proteinuria, periorbital edema, mild

hypertensionAdults may have an atypical presentation

Clinical course:>95% of children recover~60% of adults recover

Other infectious agents can cause same disease

Urine analysis was negative for hematuria and proteinuria

No reported recent history of respiratory or skin infection (no rash noted)

???

Symptoms:• Memory loss •Speech difficulties •Hypertension •Fatigue •Aggression •Irritability •Depression •Chronic fatigue

Potential exposure from well or water contamination from old lead pipes as well as diet and general environment

Nephrotoxic causing Tubulointerstitial Nephritis can be acute or chronic

Tubulointerstitial nephritis: acute or chronic injury

- Lead Blood level of 100-120 ug/dL (observed effect as low as 40 ug/dL) can lead to chronic nephropathy in adults.

- Hypertension at Lead Blood levels of 30 ug/dL (observed as low as 10 ug/dL)

- Chronic Hg exposure can be caused by chronic diuretic use and lead to renal failure

Lead: 18.9g/dl- U.S. Department of Health and Human Services recommends that BLLs among adults be reduced to under 25ug/dL

Mercury (Hg) - serum: 0 ng/ml - Acceptable levels <10 mcg/L

Conclusion: lead may be contributing to her chronic hypertension, but she is not currently exceeding recommended blood levels

Pheochromocytoma Primary Aldosteronism Cushing Syndrome Renal Artery Stenosis

AtheroscleroticFirbromusculardyplasia of renal artery

PheochromocytomaWhat is it?

Adrenal Medullary tumor Causes increased Epinephrine secretion Increased Adrenaline -> Secondary Hypertension

What fits: Hypertension (today: 170/100) Headaches

What does not No masses observed on Ultrasound Usually, order biochem test; then CT

Pheochromocytoma (not our pt!)

Primary HyperaldosteronismWhat is it?

A.K.A. : Conn’s Syndrome Adrenal Adenoma Tumor Produces Excess Aldosterone Aldo -> increases Na+ reabsorption -> increased BP

-> increases K+ excretion -> Hypokalemia

What fits Muscle complications Hypertension

What does not fit Ultrasound negative Usually, biochem test; then CT scan

‘Conn’ Tumor (not our pt!)

Cushing SyndromeWhat is it?

Excessive exposure to Glucocorticoids (Aldosterone) Buffalo Hump, Truncal obesity Two main causes:

adrenal adenoma Anterior Pituitary adenoma (“ Cushing disease”)(ACTH -> Glucocorticoids)

5:1 female

What fits Hypertension Muscle complications Gender

What does not fit Lack of physical change Negative Ultrasound Usually, biochemical abnormality; then CT (head or abdomen)

Cushing Syndrome (not our pt!)

Narrowing of the renal artery leads to• restriction of blood flow• reduced kidney function• hypertension

Causes• Atherosclerosis (most common)• Fibromuscular dysplasia

Risk Factors:High cholesterol*High blood pressure*Age*Smoker*DiabetesPeripheral vascular disease*

SxHigh blood pressure (reno-vascular

hypertension)-More than 3 needed to control

-UncontrollableBruitsSudden worsening of hypertension

Physical findings:BP 170/100A-V nicking/arteriolar narrowing

Physical findings:BP 170/100A-V nicking/arteriolar narrowingRight carotid bruitBilateral femoral artery bruits

Lab/Tests:Renal Ultrasound ($370)

-slightly decreased renal size bilaterally, no cysts or masses  

Renal MRI ($0)-non-invasive

Lab/Tests:Renal Ultrasound ($370)

-slightly decreased renal size bilaterally, no cysts or

masses  

Renal MRI ($0)

Renal Angiography ($0)-gives us best picture

-option for angioplasty

Big PictureBilateral renal artery stenosis caused a decrease

in renal blood flowKidney sensed a decrease in perfusionActivation of the renin-angiotensin-system and

aldosteroneIncreased blood pressure

Treatment:If asymptomatic no treatment necessaryBlood pressure medication

ACE InhibitorsARBDiuretics

Treatment:If asymptomatic no treatment necessaryBlood pressure medicationSurgery (75% occlusion)

Angioplasty with stentBypass

PrognosisPatients with fibromuscular dysplasia

often have good long term results with angioplasty

Those with atherosclerotic RAS frequently experience a reoccurrence and are often not completely resolved of their hypertension

Angiotensin II vasoconstricts

Prostaglandins vasodilate

•Block COX-1 and COX-2

•Inhibit synthesis of prostaglandins–Prostaglandins responsible for dilation of the afferent arteriole

•Decreased number of vasodilatory prostaglandins leading to constriction of the afferent arteriole

•Decrease in intraglomerular pressure

•Avoid NSAID use in bilateral renal artery stenosis

Competitive inhibitor of ACE

Prevents conversion of Ang I → Ang II

Decreased levels of Ang II Ang II maintains constriction of efferent arteriole

Results in dilation of the efferent arteriole

Decreases GFR

ACEI/ARBs should be avoided in bilateral renal artery stenosis

Discontinue Ibuprofen 400 mg po TID for OA

Discontinue Enalapril 10 mg po QDay SCr increased by more than 30% within two weeks (1.5

mg/dL to 3.7 mg/dL)

Discontinue Hydrochlorothiazide 50 mg po QDay due to GFR < 30 ml/min Use MDRD equation to determine GFR GFR = 186 x (3.7 mg/dL^-1.154) x (66^-0.203) x 0.742

(female) GFR = 13 ml/min Reevaluate need for medication once treatment of renal

artery stenosis has occurred

Reduce dose of Aspirin to 81 mg QDay Provide anti-platelet effect without producing anti-

inflammatory effect

Increase dose of Atorvastatin to 80 mg po every evening LDL goal of <100 mg/dL (patients current LDL is 111

mg/dL) Monitor for joint aches and pain

Initiate Tylenol 1 gm TID – QID for OA Do not exceed 4000 mg/day

Continue Amlodipine 5 mg QDay Monitor BP after medical intervention to assess need

Initiate Atenolol 50 mg po QDay AHA recommends use of beta-blocker for treatment of

HTN in patients with angina

Initiate Nitroglycerin 0.4 mg sublingual every 5 minutes for anginal pain. Max of 3 doses in 15 minutes.

UA - $40Creatinine – U = $20; P = $40Pelvic Ultrasound - $370Renal artery MRIRenal artery angiogramLipids - $82Liver Panel - $98Electrolytes - $80TSH - $58Lead and Mercury ANA - $76

Which of the following is a cause of secondary hypertension?A) PheochromocytomaB) Primary Aldosteronism (Conn’s Syndrome)C) Renal artery stenosisD) Cushing’s syndromeE) All of the above

What common infection may occur prior to glomerulonephritis?A) Infectious MonoB) ChlamydiaC) StrepD) StaphE) Whooping Cough

What is the best estimate of GFR?A) Urine Na+B) Urine outputC) Plasma K+D) Creatinine clearanceE) Plasma osmolarity

Nephrotic syndrome differs from nephritic syndrome because, in Nephrotic syndrome you see:A) hyperglycemia, hyperlipidemia, edemaB) hypoglycemia, C) hyperlipidemia, proteinuria (>3.5gm/d),

hematuriaD) hematuria, hypertension, recent infectionE) >3.5gm/d proteinuria, Hypoalbuminemia,

Lipiduria

Dr. Alan JohnsBonnie PetersonMatt ColemanEveryone for attending this morning!