A 64-year-old woman comes to the emergency department due to headache and nausea over the last 2 days. She has end-stage renal disease due to advanced diabetic nephropathy and recently started hemodialysis. In addition, the patient has anemia due to chronic kidney disease and is receiving treatment with erythropoietin and parenteral iron. Medical history is notable for mild hypertension, osteoporosis, and hypothyroidism. Blood pressure is 210/121 mm Hg and pulse is 76/min. Muscle strength is normal and sensory examination is unremarkable. There are no heart murmurs. Ophthalmoscopic examination shows bilateral retinal hemorrhages. Fingerstick glucose level is 186 mg/dL. Which of the following is the most likely cause of this patient's current condition?

Question

A 64-year-old woman comes to the emergency department due to headache and nausea over the last 2 days.  She has end-stage renal disease due to advanced diabetic nephropathy and recently started hemodialysis.  In addition, the patient has anemia due to chronic kidney disease and is receiving treatment with erythropoietin and parenteral iron.  Medical history is notable for mild hypertension, osteoporosis, and hypothyroidism.  Blood pressure is 210/121 mm Hg and pulse is 76/min.  Muscle strength is normal and sensory examination is unremarkable.  There are no heart murmurs.  Ophthalmoscopic examination shows bilateral retinal hemorrhages.  Fingerstick glucose level is 186 mg/dL.  Which of the following is the most likely cause of this patient's current condition?

Quizplus · Accepted Answer

This patient with end-stage renal disease has severe hypertension, headache, and retinal hemorrhages consistent with acute hypertensive crisis. This should raise suspicion for erythropoietin-related hypertension, given the patient's erythropoietin therapy for anemia of chronic kidney disease (CKD). Patients with CKD frequently develop a hypoproliferative anemia due to inadequate production of erythropoietin by the kidneys. Erythropoiesis-stimulating agents (ESAs), such as recombinant erythropoietin and darbepoetin, stimulate red blood cell production and are the treatment of choice in CKD-related anemia. All patients with significant renal failure and a hemoglobin <10 g/dL are candidates for ESAs after iron deficiency has been ruled out. Up to 30% of patients on erythropoietin therapy develop new or worsening hypertension, which typically occurs 2-8 weeks after treatment initiation. Hypertension is generally mild but can be severe, leading to end-organ damage (eg, encephalopathy, seizures). Large doses of erythropoietin or rapidly rising hemoglobin soon after administration increase the risk of hypertension. Therefore, patients started on erythropoietin require close blood pressure monitoring. (Choices A and D) Cerebellar hemorrhage can present with headaches, nausea, retinal hemorrhages, altered mental status, and hypertension but would typically be associated with an abnormal neurologic examination. Fibrinoid necrosis of renal arterioles is a sequela rather than a cause of severe uncontrolled hypertension. (Choice B) Cerebral venous thrombosis causes headaches, nausea, and papilledema with retinal hemorrhages; however, it is not associated with severe hypertension and, in adults, it often occurs in young women with risk factors (eg, hypercoagulable states, oral contraceptives). (Choice E) Osmotic shifts during hemodialysis can cause dialysis disequilibrium syndrome, which causes changes in neurologic status due to cerebral edema and may cause a headache and nausea. It is not associated with severe hypertension and is unlikely in this patient with no evidence of neurologic dysfunction. Educational objective: Erythropoietin is the treatment of choice for anemia related to chronic kidney disease. Hypertension is a common side effect of erythropoietin; patients who receive large doses or experience a rapid rise in hemoglobin concentration are at highest risk. References: Erythropoietin and resistant hypertension in CKD. (http://www.ncbi.nlm.nih.gov/pubmed/25416663)

A 64-Year-Old Woman Comes to the Emergency Department Due to Headache