Case Presentation: A 33-year-old Asian female with no known past medical history presented to urgent care with a severe headache and was found to have markedly elevated blood pressure (BP), prompting referral to the emergency department, where her initial BP measured 240/140 mmHg. A CT head revealed no evidence of acute intracranial pathology. Laboratory (lab) evaluation demonstrated acute renal failure, leading to admission for hypertensive emergency. A nicardipine infusion was initiated for BP control. Given her age and severity of presentation, an extensive evaluation for secondary hypertension (HTN) was pursued. Differentials: Lab studies were notable for nephrotic-range proteinuria (NRP) and electrolyte derangements. Hyperaldosteronism and pheochromocytoma were ruled out by an aldosterone/renin ratio of 6, serum metanephrines were not elevated, and abdominopelvic CT was without adrenal masses. Membranous nephropathy was less likely as PLA2R IgG antibody was 1.8. Scleroderma renal crisis and lupus nephritis were also considered; however, there were no compatible clinical features, RNA polymerase III antibody was weakly positive, complements were normal, and BP improved with amlodipine. MRA of the renal artery did not show stenosis, and infectious serologies were nonreactive. Kidney biopsy revealed IgA nephropathy (IgAN) with 80% global glomerulosclerosis, confirming advanced glomerular disease as the underlying etiology. Management: While awaiting biopsy results, treatment focused on managing the HTN emergency and correcting electrolyte abnormalities. After confirming the diagnosis of advanced IgAN and persistent metabolic disturbances, the patient was initiated on peritoneal dialysis, consistent with her preference. Outcome: BP was initially stabilized with a nicardipine drip, then transitioned to amlodipine and hydralazine for maintenance. She was discharged with arrangements for outpatient peritoneal dialysis and nephrology follow-up. She received counseling on renal replacement therapy options, including evaluation for kidney transplantation. Lesson: Severe HTN in young adults warrants prompt evaluation for secondary causes. Renal parenchymal disease, including glomerular pathologies such as IgAN, may present with minimal clinical signs aside from elevated BP. Timely workup and biopsy are critical when NRP and renal impairment are present. In advanced glomerular disease, management extends beyond BP control to include renal replacement planning.
Mushtaq et al. (Mon,) studied this question.