Hypertensive Nephrosclerosis and Renovascular Disease — Written Clinical Reasoning

Model answer — Part A: the young hypertensive with a bruit

Frame it. New severe hypertension in a non-smoking woman under 40 with a renal bruit is a secondary-hypertension trigger phenotype; the leading diagnosis is fibromuscular dysplasia of the renal artery, the dominant renovascular disease of young women in registry data ^[1]. Before imaging, confirm the pressure is real (standardised office or ambulatory readings), confirm adherence and doses, and send the screening bloods — electrolytes, creatinine, urinalysis and an aldosterone-renin ratio, since primary aldosteronism remains common even in the young ^[4].

Investigations, in sequence. Duplex ultrasound first if the local laboratory is skilled — safe, no contrast, and functionally informative — otherwise proceed straight to CT or MR angiography, which have near-catheter accuracy; in a 34-year-old needing possible surveillance, MRA avoids radiation and iodinated contrast ^[8]. The expected finding is a multifocal string-of-beads lesion of the mid-to-distal renal artery. Because FMD is a systemic arteriopathy, image the cervicocephalic vessels once (headache, pulsatile tinnitus and dissection risk make this part of complete care) ^[2].

Management. Renal FMD driving hypertension is treated with percutaneous balloon angioplasty without a stent — the meta-analysis shows high technical success with hypertension cure or improvement in a large fraction of patients, and the young with short hypertension duration do best ^[3]. Continue antihypertensives until the procedure, recheck pressure and renal function after it, and arrange surveillance imaging because restenosis occurs in a minority ^[2]. Close with what you would NOT do: apply atherosclerosis trial evidence to justify lifelong medication alone in a 34-year-old with a curable lesion ^[3].