HTN Renal Disease / Vasculitis

Question 1

What disease processes can result in renal HTN?

Answer 1

1. Pheochromocytoma
2. Primary Aldosteronism
3. Artheroscelrosis
4. Cushing’s
5. Hypothyroidism and Hyperthyroidism
6. Hyperparathyroidism

Question 2

At what BP would you start to be concerned over Malignant HTN?

Is this often associated with hypertensive emergency or urgency?

Answer 2

> 180/120 mmHg

HTN Emergency

Question 3

What are the retinal manifestations of Malignant HTN?

What about HTN Encephalopathy?

Answer 3

Retinal: Hemorrhages, Exudates, Papilledema

Encephalopathy: Cerebral Edema, SAH, Lacunar Infarctions

Question 4

What may be present on UA in a patient with Malignant HTN?

Renal Biopsy?

Answer 4

UA: Hematuria, Proteinuria

Biopsy: Fibrinoid Fibrosis

Question 5

How is Malignant HTN treated?

Answer 5

IV Labetalol
IV Nitroprusside
Nicardipine

Question 6

__________ HTN is one of the most common causes of secondary HTN.

It can often present as an acute onset of severe resistant increase in BP at a young age, refractory HTN, flash pulmonary edema, or an increase in sCr after starting ACEi

Answer 6

Renovascular HTN

Question 7

If on US you noticed a unilaterally smaller kidney, what underlying disorder (regarding BP) may be present?

Answer 7

Renovascular HTN

Question 8

Are Doppler US, CTA, MRA, and Aortogram all viable imaging modalities for renovascular HTN work up?

What is most diagnostic and therapeutic if renal artery stenosis is involved?

Answer 8

Yes

Angiography

Question 9

T/F: Medical Management (ie: anti-hypertensives) is given to all patients with renovascular HTN

Answer 9

True

Question 10

Other than medical therapy, what additional treatment options are available for renovascular HTN?

Answer 10

Angioplasty with stenting
Surgical Revascularization
Nephrectomy (of the “pressor” kidney)

Question 11

_________ disease results from cholesterol crystal break off from a plaque and embolize distally from their origin

Answer 11

Atheroembolic Disease

Question 12

T/F: Atheroembolic Disease is typically Iatrogenic

Answer 12

True

Question 13

What are examples of iatrogenic events that may result in atheroembolic disease?

Spontaneous?

Answer 13

Iatrogenic: Angiography, Cardiovascular Surgery, Anti-coagulation

Spontaneous: Hemodynamic Stress

Question 14

What is the classic clinical triad of atheroembolic disease?

Answer 14

1. Precipitating Event (Cardiac Procedure, Angiography, etc…)
2. Subacute or AKI
3. Blue Toe Syndrome / Livedo Reticularis

Question 15

What may be seen on fundoscopy in a patient with atheroembolic disease?

Answer 15

Hollenhorst Plaque in a retinal artery

Question 16

How may the renal artery appear on histology in a patient with atheroembolic disease?

Answer 16

Cleft Like Spaces in the the lumen

Question 17

How is Atheroembolic managed?

Answer 17

Supportive:

Statins
ASA
Anti-HTN
Smoking Cessation
Glucose Control

Question 18

What percentage of patients with with atheroembolic disease progress to ESRD?

Answer 18

1/3rd

Question 19

What FIVE ‘things’ compose Thrombotic Microangiopathies?

Answer 19

1. Thrombocytopenia
2. Microangiopathic Hemolytic Anemia
3. Neurological Sx
4. Renal Function Abnormalities
5. Fever

Question 20

T/F: Idiopathic TTP-HUS is NOT a medical emergency

Answer 20

False

It is a medical emergency (fatal if not treated)

Question 21

What is the most diagnostic study in diagnosing thrombotic microangiopathies?

What would be seen on this?

Answer 21

Biopsy

Schistocytes

Question 22

What deficiency is often found in patients with thrombotic microangiographies?

Answer 22

ADAMTS13

Question 23

What are examples of ANCA associated vaculitis?

Answer 23

1. Wegner’s (Granulomatosis with polyangitis) - GPA
2. Microscopic Polyangitis - MPA
3. Churg-Strauss Syndrome - CSS
4. Renal Limited Vasculitis

Question 24

How is MPA distinguished from GPA and CSS?

Answer 24

Absence of granuloma formation in the presence of necrotizing vasculitis.

Question 25

Will GPA, MPA, or CSS have immune complex deposits on histology?

Answer 25

No

Question 26

What are unique clinical manifestations of GPA?

Answer 26

1. Nasal and Oral Inflammation (Ulcers, Purulent/Bloody discharge) 2. CXR with nodules, infiltrates, or cavities 3. Abnormal urinary sediment (hematuira +/- RBC casts) 4. Granulomatous inflammation on biopsy of an artery or perivascular area

Question 27

If a patient had a stenonic renal artery what may be auscultated on examination?

Answer 27

Renal Artery Bruit

Question 28

In _____ vasculitis, 50% of the glomeruli are normal

Answer 28

Focal

Question 29

In _____ vasculitis, 50% of the glomeruli have (Cellular/Fibrotic) crescents present

Answer 29

Crescentric

Question 30

In _____ vasculitis, 50% of the glomeruli are globall sclerotic

Answer 30

Sclerotic

Question 31

Is GPA associated with PR3-ANCA or MPO-ANCA? What about MPA?

Answer 31

GPA: PR3-ANCA MPA: MPO-ANCA

Question 32

T/F: A Vasuclitis diagnosis (GPA or MPA) needs to be confirmed by biopsy

Answer 32

True

Question 33

What combination of medications is used to treated vasculitis?

Answer 33

Cyclophosphamide and Steroids

Question 34

If angiography is preformed and the damaged kidney can not be saved, what needs to occur?

Answer 34

Nephrectomy