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Hypertensive Nephrosclerosis and Renovascular Disease — Written Clinical Reasoning
DCE written preparation: structured reasoning for renovascular scenarios — the young woman with a bruit and the older vascular patient with a creatinine rise on ACE inhibition.
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FRACP DCEMRCP Part 2
Prompt
DCE written preparation: structured reasoning for renovascular scenarios — the young woman with a bruit and the older vascular patient with a creatinine rise on ACE inhibition.
SAQ — Renovascular disease: FMD and the ACEi creatinine rise (20 marks, 30 minutes)
Prompt: Answer both parts, addressing the diagnostic reasoning, investigation sequence, management with the revascularisation decision, and follow-up. Justify each decision with reference to evidence. [7]
Case vignette Part A: A 34-year-old non-smoking woman presents with new severe hypertension and a renal bruit. [1]
Case vignette Part B: A 66-year-old man with resistant hypertension and a 2 cm asymmetric kidney has a creatinine rise from 110 to 138 micromol/L after ACE inhibitor uptitration. [7]
References8ShowHide
- [1]Olin JW, Froehlich J, Gu X, et al. The United States Registry for Fibromuscular Dysplasia: results in the first 447 patients Circulation, 2012.PMID 22615343
- [2]Persu A, Giavarini A, Touzé E, et al. European consensus on the diagnosis and management of fibromuscular dysplasia J Hypertens, 2014.PMID 24842696
- [3]Trinquart L, Mounier-Vehier C, Sapoval M, et al. Efficacy of revascularization for renal artery stenosis caused by fibromuscular dysplasia: a systematic review and meta-analysis Hypertension, 2010.PMID 20625080
- [4]Carey RM, Calhoun DA, Bakris GL, et al. Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association Hypertension, 2018.PMID 30354828
- [5]Cooper CJ, Murphy TP, Cutlip DE, et al. Stenting and medical therapy for atherosclerotic renal-artery stenosis N Engl J Med, 2014.PMID 24245566
- [6]Wheatley K, Ives N, Gray R, et al. Revascularization versus medical therapy for renal-artery stenosis N Engl J Med, 2009.PMID 19907042
- [7]Textor SC Current approaches to renovascular hypertension Med Clin North Am, 2009.PMID 19427501
- [8]Williams GJ, Macaskill P, Chan SF, et al. Comparative accuracy of renal duplex sonographic parameters in the diagnosis of renal artery stenosis: paired and unpaired analysis AJR Am J Roentgenol, 2007.PMID 17312071