by Karl F. Hilgers, MD, FASN Department of Nephrology and Hypertension, University of Erlangen-Nuremberg, Erlangen, Germany
A Nephrology Consultant was asked to evaluate a 58-year-old male, white patient who had been admitted to the hospital 2 days previously due to refractory hypertension.
Current complaints Sphygmomanometric blood pressure recordings on the ward revealed levels up to 240 mm Hg systolic and 120 mm Hg diastolic pressure, despite continuous treatment with 6 antihypertensive drugs. There was no headache, visual impairment, confusion, dizziness, chest pain, dyspnea, joint pain or other current complaints. The patient’s weight was constant, his appetite and bowel habits were unremarkable. He slept well except for occasional nycturia. He reported no further abnormalities of urine frequency or colour, and no pain during urination.
Previous medical history Arterial hypertension had been diagnosed more than 15 years before. At home, the patient used his own sphygmomanometer and reported measurements of about 160 / 90 mm Hg. A nuclear magnetic resonance tomography performed several months previously revealed lacunar brain lesions. An echocardiography performed the day before showed marked left ventricular hypertrophy. Diabetes mellitus type 2 had been diagnosed in 1995. Oral medications had been used to control blood sugar levels for several years; two or three years ago, insulin was added. During the last years, measurements of HbA1c showed levels below 6.5%, indicating a good control of blood glucose. The last fundoscopic investigation, performed one year ago, reportedly showed hypertension-induced alterations but no evidence of diabetic retinopathy. The patient reported that high cholesterol levels had been measured. He was not aware of other previous diseases. He reported no heart or kidney disease. The patient had not smoked for 15 years but had smoked 10 cigarettes per day for 25 years before that time. He reported occasional consumption (less than twice a week) of up to 1 L of beer. The patient is a qualified engineer and runs his own business. He is married and has one daughter. The family history was positive for hypertension (the patient’s father and one grandfather) and diabetes mellitus (one grandmother) but not for kidney disease. The patient’s father died of a stroke.
Current medication Ramipril 5mg twice a day Candesartan cilexetil 16 mg twice a day Hydrochlorothiazide 12.5 mg once per day Metoprololsuccinat 47,5 mg extended release twice a day Amlodipine 5 mg twice a day Moxonidine 0.4 mg twice a day Metformine 850mg twice a day Glimepirid 2mg twice a day Insulin Glargin 14 units in the evening Potassium chloride supplements in varying doses
Physical examination The blood pressure was 210/105 mmHg measured on the right arm, and 205/100 mmHg on the left arm. The heart rate was 56/min, breathing 12/min. The temperature was 36.8°C. The patient was 175 cm tall and weighed 76 kg. The physical examination was unremarkable except for a prominent, lateralized heartbeat. Breathing sounds were normal, and there were no rales. No bruits were heard over the neck or abdomen. There was no edema. The peripheral pulses were normal. There were no abnormalities of consciousness, muscle strength, or sensitivity.
Question 1) - Given the information available so far, what is the most likely cause of the patient’s high blood pressure? (Only ONE answer is correct)