Free nephrology board questions: HTN

A 56-year-old man with hyperlipidemia treated with pravastatin establishes care. He feels well, has a sedentary lifestyle, and does not use tobacco. BP is 158/97 mm Hg and BMI is 30 kg/m²; examination is otherwise unremarkable. Basic metabolic panel, complete blood count, and urinalysis are normal. Total cholesterol is 180 mg/dL and HDL 32 mg/dL. ECG shows sinus rhythm with left axis deviation. After 2 weeks of twice-daily home monitoring, his average home BP is 156/94 mm Hg. He receives counseling on a low-sodium, heart-healthy diet and regular physical activity and appears motivated. What is the most appropriate next step?

A 57-year-old man with a history of hypertension and coronary artery disease presents to the emergency department with headache and blurry vision for the last 24 hours. He denies chest pain. Medications include amlodipine, hydrochlorothiazide, and lisinopril. He notes that he was recently traveling and forgot several doses of his medications. Home BP is typically 150–160/90–100 mm Hg. BP is 224/122 mm Hg, heart rate is 62/min, and body mass index is 38 kg/m². Heart examination is notable for an S4 gallop. Lung examination reveals fine crackles at both bases. Fundoscopic examination shows papilledema. Laboratory data: hemoglobin 11 g/dL (reference 14–18); platelet count 120,000/μL (150,000–450,000); haptoglobin 60 mg/dL (83–267); lactate dehydrogenase 420 U/L (80–225); troponin I 0.04 ng/mL (≤0.04); creatinine 2.1 mg/dL (baseline, 1.3) (0.7–1.3). EKG shows left ventricular hypertrophy but no ST segment deviations or T-wave abnormalities. Chest x-ray shows increased opacities at both lung bases and a normal mediastinum. Which of the following is the next BEST step in management?

A 61-year-old man with type 2 diabetes is evaluated for resistant hypertension. He was diagnosed with hypertension 15 years ago. His BP has been poorly controlled despite adherence to his medication regimen and a sodium-restricted diet. His family history is significant for hypertension in several relatives, most of whom were diagnosed between the ages of 40 and 50 years. Recent home BP readings are 150/80–160/90 mm Hg. Medications include ramipril, amlodipine, and labetalol. Physical examination reveals BP 154–158/86–92 mm Hg in both arms, with a heart rate of 62/min. The heart and lung examinations are normal, and there is no edema. Laboratory data: Serum: sodium 139 mEq/L (reference 136–145); potassium 4.7 mEq/L (3.5–5.0); chloride 104 mEq/L (98–106); total CO₂ 23 mEq/L (23–28); BUN 17 mg/dL (8–20); creatinine 1.3 mg/dL (0.7–1.3). Urine: albumin-to-creatinine ratio 182 mg/g (<30 mg/g). Which ONE of the following is the MOST APPROPRIATE addition to this patient's antihypertensive regimen?

A 68-year-old man with hypertension, diabetes, and CKD stage 4 reports increasing pedal edema and rising home BP readings averaging 150/80 mm Hg. He adheres to a diet of <2 g sodium daily. Medications are losartan, dapagliflozin, and insulin. Office BP is 155/65 mm Hg. Lungs are clear, and he has 1+ bilateral lower-extremity edema to the shins. Potassium is 4.9 mEq/L and creatinine 2.8 mg/dL. What is the most appropriate next step?

A 59-year-old man is evaluated for refractory hypertension. He was diagnosed with hypertension and type 2 diabetes 15 years ago. His BPs have not been at goal for many years, but has recently worsened. The patient gained weight after starting insulin a few months ago despite exercising for 30 minutes daily. Clinic BP averages 150–160/90–100 mm Hg, and similar values are obtained at home. Recent ambulatory BP monitoring shows an average BP of 148/90 mm Hg. There is no history of headaches, paroxysmal hypertension, palpitations, sweating, or family history of hypertension. He does not smoke, drink alcohol, or use illicit drugs. He does not take NSAIDs. He has been adherent to a sodium-restricted diet. Antihypertensive medications include losartan, chlorthalidone, and nifedipine at the maximally-tolerated doses, as well as insulin, metformin, and atorvastatin. On examination, BP is 154/94 mm Hg, and body mass index is 38 kg/m². Funduscopic examination shows grade 2 hypertensive retinopathy and mild diabetic retinopathy. The remainder of the examination is normal. Laboratory data: serum sodium 142 mEq/L (reference 136–145); potassium 3.8 mEq/L (3.5–5.0); chloride 108 mEq/L (98–106); total CO₂ 25 mEq/L (23–28); BUN 32 mg/dL (8–20); creatinine 1.2 mg/dL (0.7–1.3); aldosterone 9.1 ng/dL (≤10 supine or seated, <21 standing); renin 1.1 ng/mL/h (0.3–2.5 supine, 0.2–3.6 upright). Urine: albumin-to-creatinine ratio 462 mg/g (<30); sodium 58 mEq/L (varies with intake); potassium 38 mEq/L (varies with intake); creatinine 81 mg/dL (varies with intake). Which of the following is the next BEST STEP in management?

A 51-year-old woman is evaluated for resistant hypertension. She presented 5 months ago to her primary care physician with a 3-week history of headaches, tinnitus, dizziness, and shortness of breath. BP was 182/94 mm Hg, increased from 124/72 mm Hg 1 year previously. Her 50-year-old brother and 75-year-old father both developed hypertension in their 30s. Medications include amlodipine, carvedilol, indapamide, and hydralazine. On examination, BP in the right arm is 174/88 mm Hg, BP in the left arm is 169/85 mmHg, heart rate is 84/min, and body mass index (BMI) is 34 kg/m². On auscultation, there are left-sided carotid and epigastric bruits. Laboratory data show serum creatinine level of 0.9 mg/dL (reference range, 0.5–1.1), potassium level of 3.6 mEq/L (reference range, 3.5–5.0), and total CO₂ level of 29 mEq/L (reference range, 23–28). Urinalysis is normal. Duplex Doppler ultrasound of the left carotid artery reveals turbulence and increased flow velocity. Which ONE of the following is the best NEXT STEP in evaluating hypertension?

A 56-year-old man with hypertension, type 2 diabetes, and CKD G3/A2 is evaluated after an uneventful elective open cholecystectomy. Home medications (amlodipine, lisinopril, hydrochlorothiazide, and glipizide) were all stopped on admission because he was NPO. He is tolerating clear liquids on postoperative day 2. BP is 178/110 mm Hg. Heart, lung, and abdominal examinations are unremarkable, and there is no edema. Sodium 138, potassium 4.4, total CO₂ 23 mEq/L; creatinine 1.4 mg/dL (stable); urine albumin-to-creatinine ratio 75 mg/g. What is the best next step in managing his hypertension?

A 70-year-old man with CKD stage G3b/A1 receiving therapy with sunitinib for metastatic renal cell carcinoma is referred to evaluate new-onset hypertension. He denies dyspnea, peripheral edema, or headache. BP is 158/90 mm Hg, increased from 132/76 mm Hg last month. Fundoscopic examination shows no papilledema. There is trace edema bilaterally. Neurologic examination is normal. Laboratory data: blood WBC count 10,400/µL (reference 4000–11,000); hemoglobin 11.4 g/dL (14–18); platelet count 310,000/µL (150,000–450,000); creatinine 1.6 mg/dL, stable (0.7–1.3). Urine studies: protein-to-creatinine ratio 0.3 mg/mg (<0.2). Urinalysis shows 1+ albumin and no blood, with negative microscopy. Peripheral blood smear shows no schistocytes. Which ONE of the following is the best NEXT STEP in management?