A 42-year-old woman comes to the office for evaluation of elevated blood pressure. She says, "I checked my blood pressure on a machine at the pharmacy, and it was 160/90 mm Hg. The pharmacist said I should see a doctor." The patient has no history of hypertension and has had no chest pain, headache, or focal weakness or numbness. She notes occasional episodes of pain in her flanks, which she ascribes to muscle tension. The patient has had several urinary tract infections over the course of her life but has no chronic medical problems and takes no medication regularly. She does not use tobacco, alcohol, or illicit drugs. The patient is married and has a son. Her mother has hypertension, her father died at an early age in a motor vehicle collision, and her uncle has renal failure and receives dialysis. Blood pressure is 156/94 mm Hg on the right arm and 152/96 mm Hg on the left arm. Pulse is 80/min and respirations are 16/min. Jugular venous pressure is within normal limits. Breath sounds are normal bilaterally with no crackles. Point of maximal impulse is displaced to the left and down. Heart sounds are normal with no murmur or gallops. The abdomen is soft with bilateral flank fullness. Bowel sounds are active. Laboratory results are as follows. Urinalysis shows dysmorphic erythrocytes and mild proteinuria. ECG shows left ventricular hypertrophy with nonspecific ST-T wave changes. Imaging reveals enlarged kidneys with multiple bilateral cysts. Which of the following is the best management for this patient?

Question

A 42-year-old woman comes to the office for evaluation of elevated blood pressure.  She says, "I checked my blood pressure on a machine at the pharmacy, and it was 160/90 mm Hg.  The pharmacist said I should see a doctor."  The patient has no history of hypertension and has had no chest pain, headache, or focal weakness or numbness.  She notes occasional episodes of pain in her flanks, which she ascribes to muscle tension.  The patient has had several urinary tract infections over the course of her life but has no chronic medical problems and takes no medication regularly.  She does not use tobacco, alcohol, or illicit drugs.  The patient is married and has a son.  Her mother has hypertension, her father died at an early age in a motor vehicle collision, and her uncle has renal failure and receives dialysis.  Blood pressure is 156/94 mm Hg on the right arm and 152/96 mm Hg on the left arm.  Pulse is 80/min and respirations are 16/min.  Jugular venous pressure is within normal limits.  Breath sounds are normal bilaterally with no crackles.  Point of maximal impulse is displaced to the left and down.  Heart sounds are normal with no murmur or gallops.  The abdomen is soft with bilateral flank fullness.  Bowel sounds are active.  Laboratory results are as follows.  Urinalysis shows dysmorphic erythrocytes and mild proteinuria.  ECG shows left ventricular hypertrophy with nonspecific ST-T wave changes. Imaging reveals enlarged kidneys with multiple bilateral cysts.  Which of the following is the best management for this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c09b_5b71_8f63_1ff6d7bee327_MD0005_00 Autosomal dominant polycystic kidney disease (ADPKD) usually causes slowly progressive renal insufficiency. Although no specific therapies are available to halt the illness, rigorous control of blood pressure with ACE inhibitors has been shown to reduce the rate of renal decline. Aggressive control of lipid levels using statins is also recommended to limit risk of cardiovascular disease. (Choice A) Patients with ADPKD do not appear to be at increased risk of renal carcinoma. Bilateral nephrectomy is not required. Focus should be placed on reducing the risk of renal failure and cardiovascular disease. (Choice B) Most patients with ADPKD are diagnosed when renal ultrasound shows enlarged kidneys with multiple bilateral cysts. Genetic testing is usually reserved for those with suspected ADPKD who do not have a clear diagnosis by ultrasound. (Choice C) Renal ultrasound is not typically used for monitoring progression of ADPKD as sensitivity is too low to determine rate of cyst growth. (Choice E) Patients with ADPKD are at increased risk of berry aneurysms, but a screening MRI of the brain is typically reserved for the minority with high-risk features (eg, family history of intracranial bleed, previous intracranial bleed). Although patients with ADPKD often have liver and pancreas cysts, a screening MRI of the abdomen is not necessary. Educational objective: ACE inhibitors are considered the drug of choice to control hypertension and prevent progression of chronic kidney disease in patients with autosomal dominant polycystic kidney disease.

A 42-Year-Old Woman Comes to the Office for Evaluation of Elevated