Nephrology Complicated Hypertension: Review Questions Ursula C. Brewster, MD, and Mark A. Perazella, MD, FACP Dr. Brewster is a fellow in nephrology, Yale University School of Medicine, New Haven, CT. Dr. Perazella is an associate professor of medicine and director of the renal fellowship program, Yale University School of Medicine. Choose the single best answer for each question.
	1. A 28-year-old obese woman presents to her doctor’s office with persistent headache and malaise. She is otherwise healthy. Blood pressure measured in the office is 190/110 mm Hg. Serum electrolytes demonstrate hypokalemia (serum potassium, 3.0 mEq/L) and metabolic alkalosis (serum bicarbonate, 32 mEq/L) with normal kidney function. Urinalysis reveals no proteinuria, cylinduria, or casts. A secondary cause of hypertension is considered. Renal ultrasound shows normal echogenicity, with the right kidney 12.0 cm and the left kidney 10.5 cm in length. Doppler examination is technically limited by her obesity. A renal angiogram reveals significant stenosis (90%) of the left renal artery due to fibromuscular dysplasia. What is the best management option for this patient at this point? Perform renal artery bypass Serial ultrasonography to assess kidney size Perform percutaneous angioplasty of the stenotic lesion Start an angiotensin-converting enzyme (ACE) inhibitor and titrate to control blood pressure Click here to compare your answer. 2. A 76-year-old man with a past history of non– insulin-dependent diabetes mellitus and hypertension is seen in the office. His blood pressure is 140/85 mm Hg, and he has mild renal insufficiency (serum creatinine, 1.4 mg/dL). Urinalysis reveals 2+ protein on dipstick but no cylinduria. Blood pressure medications include hydrochlorothiazide and atenolol. What antihypertensive agent will best control blood pressure and preserve renal function in this patient? Amlodipine Furosemide Lisinopril Verapamil Click here to compare your answer.		3. A 4-year-old girl is brought to her pediatrician’s office with lower extremity weakness and inability to walk. She is afebrile, but her blood pressure is 130/80 mm Hg. Routine serum chemistries show profound hypokalemia and metabolic alkalosis. Hypokalemia is the suspected cause of her lower extremity weakness. Further history reveals that the child ate an entire candy dish of authentic black licorice at her grandmother’s house. What hormone caused the syndrome with which this child presents? Aldosterone Cortisol Dihydrotestosterone Progesterone Click here to compare your answer. 4. A 35-year-old healthy man is referred for hypertension. His blood pressure is 190/105 mm Hg and laboratory tests show hypokalemia (serum potassium, 2.1 mEq/L) and metabolic alkalosis (serum bicarbonate, 36 mEq/L) with normal renal function. Given his age, there is concern for secondary causes of hypertension. The plasma renin activity (PRA) level is low (0.5 ng/mL per hour), the plasma aldosterone concentration (PAC) is high (22.5 ng/dL), and the PAC:PRA ratio is 45. After 3 days of oral salt loading, the patient collects a 24-hour urine sample that reveals an elevated aldosterone concentration (> 14 mg/day). What is the next step in the workup of this patient’s hypertension? Bilateral renal vein sampling Captopril renal scan Computed tomography (CT) scan of the abdomen Renal artery angiogram Click here to compare your answer.
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