Clinical Correlations The NYU Langone Online Journal of Medicine

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Clinical Correlations The NYU Langone Online
Journal of Medicine
http//clinicalcorrelations.org
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NYU Medicine Grand Rounds Clinical Vignette

• Leslie Park, MD
• PGY2
• 1/8/14

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Chief Complaint

• 45 year old African American man referred to
  Renal clinic for uncontrolled hypertension for
  five years.

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History of Present Illness

• The patient reports a history of hypertension
  since the age of 21.
• Hypertension has been managed by a variety of
  medications over the years, including diltiazem,
  atenolol, clonidine, hydrochlorothiazide,
  minoxidil, methyldopa, amlodipine, labetalol.
• He complains of intermittent headaches.
• He also has chronic chest pain for which he has
  never had a stress test because his blood
  pressure has always been too elevated.
• In 2011, the patient was referred to Renal clinic
  for further management of refractory hypertension
  and renal disease.
• The patients renal disease consists of a long
  history of proteinuria and mild renal dysfunction
  of unclear etiology.

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Additional History

• Past Medical History
• Hypertension
• CKD
• Polysubstance abuse (tobacco, alcohol, crack,
  heroin)
• Bipolar disease
• Past Surgical History denies
• Social History
• Tobacco 2 packs per day for 40 years
• Alcohol stopped 2 years ago
• Remote cocaine, heroin
• Family History
• Mother myocardial infarction, diabetes.
• Allergies
• Nifedipine and Quinapril rash, angioedema.
• Medications
• Minoxidil 10mg daily, furosemide 20mg daily,
  amlodipine 10mg daily, losartan 50mg daily,
  aspirin 81mg daily, simvastatin 20mg daily,
  tramadol 100mg q6h prn

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Physical Examination

• African American male sitting in a chair
  comfortably not in acute distress
• Vital Signs T96.9 BP172/103 HR 80 RR 18, O2
  sat 97 on room air.
• Remainder of Physical Exam was normal

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Blood Pressure Trend
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Blood Pressure Trend Graph
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Laboratory Findings

• Hemoglobin A1c 6.1
• Other labs within normal limits

Month/year Creatinine Urine protein Urine creatinine
05/1999 1.2
01/2004 1.7
10/2011 1.3 38.6 82.4
01/2012 1.4 18.4 110.6
04/2012 1.3 77.2 216.5
12/2012 1.5 6.2 39.8
08/2013 1.4 116.8 293.9
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Renal ultrasound

• Renal ultrasound (2013) normal size kidneys and
  normal echotexture. R kidney 10.4cm. L kidney
  9.5cm. Right lower pole simple renal cyst
  measuring 1.3cm. Normal intrarenal blood flow.

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Working Diagnosis

• ApoL1 gene mutation as cause for chronic kidney
  disease in this patient who is African American
  with uncontrolled hypertension.