Clinical Correlations The NYU Langone Online Journal of Medicine

NYU Medicine Grand Rounds Clinical Vignette Leslie Park, MD PGY2 1/8/14 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

45 year old African American man referred to Renal clinic for uncontrolled hypertension for five years. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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 patient’s renal disease consists of a long history of proteinuria and mild renal dysfunction of unclear etiology. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Physical Examination African American male sitting in a chair comfortably not in acute distress Vital Signs: T:96.9 BP:172/103 HR: 80 RR: 18, O2 sat: 97% on room air. Remainder of Physical Exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Blood Pressure Trend

Blood Pressure Trend: Graph

Laboratory Findings Hemoglobin A1c: 6.1 Other labs within normal limits U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Month/yearCreatinineUrine protein Urine creatinine 05/ / / / / / /

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. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

ApoL1 gene mutation as cause for chronic kidney disease in this patient who is African American with uncontrolled hypertension. Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS