December 28, 2024

30-year-old woman presents with persistently high blood pressure

By Med-Challenger · 2 minute read

A 30-year-old woman presents with persistently high blood pressure above 180/90 mm Hg; her blood pressure was checked on two separate occasions during the last week. She denies any history of a chronic medical issue such as high blood pressure or diabetes. She also denies any complaints of nausea, vomiting, visual changes, dysuria, urgency, chest pain, or shortness of breath. However, she reports a positive family history of diabetes and hypertension in her family.

During her visit with you, you note that her blood pressure is 190/96 mm Hg in the right forearm and 188/94 mm Hg in the left forearm. On physical examination, she has no jugular venous distension, swelling of the eyes, or lymphadenopathy. Cardiovascular and pulmonary examinations are normal.

Urinalysis shows:

Protein = 2+

Blood = 1+ with many RBC casts on microscopy

Ketones, red blood cells (RBCs) = Nil

White blood cells (WBCs) = 0.2/hpf

Creatinine = 0.9 mg/dL

blood urea nitrogen = 17 mg/dL

24-hour urinary proteins = 2.4 g

Complete blood count, electrolytes, liver function test, complements, and blood sugar levels are all found to be within normal limits.

Which of the following is the most appropriate step in the management of this patient's condition?

laparoscopy
skin biopsy
kidney biopsy
urine culture
cystoscopy

The correct answer is:

kidney biopsy

This patient has evidence of primary glomerular disorder as suggested by RBC casts; hematuria, proteinuria, and elevated blood pressure are also secondary to glomerular disease. In order to determine the nature of the glomerular abnormality to initiate treatment, it is important to identify the primary glomerular disease by performing a biopsy of the kidney tissue.

Cystoscopy will not show any abnormality because the hematuria, proteinuria, and casts in the urine are due to glomerular disease.

Laparoscopy or skin biopsy is unlikely to yield any strong evidence to support the most likely diagnosis in this patient.

This patient has no WBCs in the urine, so the urine culture will most likely yield no organismal growth after culture.

References:

Brosnahan G, Fraer M. Chronic kidney disease: whom to screen and how to treat, part 1: definition, epidemiology, and laboratory testing. South Med J. 2010;103(2):140-146.

Leoncini G, Ratto E, Viazzi F, Pontremoli R. The role of microalbuminuria in the overall risk assessment of hypertensive patients. [In Italian]. G Ital Nefrol. 2007;24(6):565-573.

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