Algorithm for Diagnosis and Management of Resistant Hypertension in CKD Pseudoresistant Hypertension -

Resistant Hypertension in CKD - Diagnosis and Management Algorithm #Resistant #Hypertension #CKD #Diagnosis #Management #Algorithm

When to Evaluate for Secondary Causes of Hypertension 1. Severe or resistant HTN 2. Acute rise/lability in BP 3. Malignant HTN with end organ damage or electrolyte abnormalities 4. Age <30 w/o risk factors by Angela Rao, MD @AngieRao92 via BCM IM Residency @BCM_InternalMed #Secondary #Hypertension #causes #differential #indications #diagnosis #HTN

Primary and Secondary Causes of Hypertension - Differential Diagnosis Algorithm Primary (Essential) (95%) - Onset between age 20 and 50. Positive family history. No features of secondary hypertension. • Long-standing • Uncontrolled • Drug Withdrawal Mislabelled - Repeatedly normal blood pressure when taken at home, work or when using an ambulatory monitor. • White-coat Hypertension • Masked Hypertension Secondary Causes (5%) - Onset age < 20 or > 50 years, No family history. Hypertensive urgency. Resistant hypertension. - Exogenous • Corticosteroids • Oral Contraceptive Pills • Cocaine • Black licorice • Medications - Renal • Renal parenchymal disease - CKD, AKI, Glomerulonephritis • Renovascular disease (unilateral and bilateral renal artery stenosis) - Mechanical • Aortic coarctation • Obstructive Sleep Apnea - Endocrine • Glucocorticoid excess (Cushing syndrome or disease) • Catecholamine excess (pheochromocytoma) • Mineralocorticoid excess (primary aldosteronism) • Hyperthyroidism (mainly systolic hypertension) • Hypothyroidism (mainly diastolic hypertension) • Hyperparathyroidism • Pregnancy (Gestational hypertension) #Hypertension #Primary #Secondary #HTN #Cardiology #Differential #Diagnosis #Algorithm #causes

Secondary Causes of Hypertension - Differential Diagnosis Algorithm Hypertension - BP > 140/90 (>130/80 for DM) Hypertensive urgency or emergency (any visit), Hypertension with end-organ damage or DM (visit 2), Diagnosis based on repeat clinic visits, Ambulatory blood pressure monitor, Self/Home pressure monitoring (visit 3+) Consider secondary HTN • Onset <20yo, >50yo • NO FHx • Hypertensive urgency • Refractory hypertension (multi-drug resistance) Renal Parenchymal Diseases • Glomerulonephritis • Nephritic syndrome • AKI/CKD Mineralocorticoid Excess: • Conn's syndrome • NSAlDs • Licorice • Liddle's syndrome • Bilateral RAS Vasoconstrictors: • Sympathetic nervous system (ie. cocaine, pheochromocytoma) • Steroids (Cushing's, exogenous steroids) • Renin-Angiotensin stimulation (OCP) • Alcohol abuse/ withdrawal Anatomic Causes: • Aortic coarctation • Unilateral RAS Metabolic Causes: • Hyperthyroidism • Hypercalcemia • Pheochromocytoma #Hypertension #HTN #Secondary #Nephrology #Differential #Diagnosis #Algorithm #Causes

Causes of Secondary Hypertension - Workup and Differential Diagnosis Approach (when evaluation should be done): 1. Severe or resistant hypertension: Resistant hypertension is defined as the persistence of hypertension despite concurrent use of adequate doses of three antihypertensive agents from different classes, including a diuretic. 2. An acute rise or increased lability in blood pressure developing in a patient with previously stable values. 3. Age less than 30-40 years in non-obese, non-black patients with a negative family history of hypertension and no other risk factors (eg, obesity) for hypertension. 4. Onset of diastolic hypertension at an older age (> 55 years) 5. Malignant or accelerated hypertension (eg, patientswith severe hypertension and signs of end-organ damage such as retinal hemorrhages or papilledema, heart failure, neurologic disturbance, or acute kidney injury). 6. Hypertension associated with electrolyte disorders including hypokalemia and metabolic alkalosis. 7. Proven age of onset before puberty. 8. Stage 2 hypertension (blood pressure >160-179/100-109 mm Hg) with clinical suspicion of either renovascular or endocrine causes of hypertension (eg, presence of renal bruit or signs of hormonal excess or hypokalaemia). 9. Stage 3 hypertension (blood pressure >180/110 mm Hg). Causes: • Vascular: Renal artery stenosis, Coarctation of aorta, Vasculitis • Endocrinologic: Hypothyroidism, Primary Hyperaldosteronism, Hyperthyroidism, Hypercalcemia, Cushing's syndrome, Acromegaly, Pheochromocytoma • Toxic: NSAlDs, Glucocorticoid, Estrogens, Sympathomimetic, Alcohol, Cocaine, Amphetamines • Other: 1. Renal parenchymal disease: CKD, acute glomerulonephritis, andscleroderma renalcrisis 2. Obstructive sleep apnea: CPAP, most pts have HTN 3. White-coat syndrome: 24-hour ABPM 4. Pregnancy-associated 5. Neurologic disorders: Increased intracranial pressure (Cushing'sresponse), quadriplegia, dysautonomia, and Guillain-Barre Syndrome - Dr. Jorge Cortés @Jcortesizaguirr #Secondary #Hypertension #Workup #causes #Differential #Diagnosis #indications

HFpEF and CAD Management Algorithm 1. Consider revascularization based on current guidelines for CAD and HFpEF* 2. Statins: all patients unless contraindicated 3. Aspirin: all patients unless contraindicated 4. Clopidogrel (or equivalent antiplatelet): if indicated by current guidelines (eg, recent PCl or ACS) 5. ACE inhibitor: consider in all patients unless contraindicated 6. ARB: if ACE inhibitor contraindicated 7. ß-BIocker: perform exercise testing to evaluate for Cl. If Cl, first consider pacemaker then start vasodilating ß-blocker. If no CI, treat with vasodilating ß-blocker.* 8. Angina: consider ranolazine if angina is not controlled by above medications. Also consider nitrates, calcium channel blockers. * 9. Optimal BP management: if BP is not controlled by ACE inhibitor/ARB + vasodilating ß-blocker, optimize fluid status (hypervolemia may exacerbate hypertension in patients with increased arterial stiffness), add chlorthalidone, consider spironolactone 10. Lifestyle modification: diet, exercise, cardiac rehabilitation, smoking cessation, weight loss (consider bariatric surgery in morbid obesity); treat obstructive sleep apnea 11. Enroll in HFpEF clinical trial #HFpEF #CAD #Management #Algorithm #cardiology

Diarrhea Workup and Management Algorithm in Transplant Patients First Tier Microbiologic-Testing: 1. C. difficile PCR (Stool) 2. CMV qPCR (Serum/Blood) 3. Norovirus PCR (Stool) 4. Bacterial culture (Stool) * If available consider multiplex PCR for Broad range of enteric pathogens First Tier Microbiologic-Testing: 1. Ova and Parasite evaluation (stool) 2. Giardia and Cryptosporidium EIA (Stool) 3. Breath test for bacterial overgrowth If above testing negative and diarrhea persists: 1. Adjust IS medications *Reduce dose of change to different agent 2. Colonoscopy +/- EGD *Especially if concern for PTLD, GVHD or IBD 3. Empiric therapy with probiotic or anti-motility agents 4. Evaluate for malabsorption #Diarrhea #Workup #Management #Algorithm #Transplant #diagnosis #differential

Management of Pruritus in Patients with Chronic Kidney Disease Pruritus with no primary lesions - differential diagnosis: • Renal pruritus • Liver disease/cholestatic pruritus • Hematologic pruritus (Iron deficiency anemia, Polycythemia vera) Management of Dry Skin – General Measures 1. Bathing recommendations: • Fragrance-free sensitive skin bar soap (i.e. Dove sensitive skin® bar soap) • Limit use of soap to axillae and groin/perineum • Avoid excessive bathing or bathing with hot water 2. Avoid wearing rough clothing, such as wool, over itchy areas. 3. Use mild detergent for clothes/sheets and rinse well. 4. Keep fingernails short and clean. Try not to rub or scratch the itchy areas. 5. Keep your house cool and humid, especially in the winter. 6. Topical emollients: • Fragrance-free emollient* BID to TID and especially after bathing; OR • Baby oil BID to TID; OR • Menthol 0.25%/camphor 0.25% in emollient* BID to TID • For localized pruritus: • Consider Capsaicin 0.025% cream, apply sparingly BID-QID (onset of action 2-4 weeks) • Pramoxine 1% in emollient BID-TID PRN 7. Consider acupuncture • Malignancy (leukemia, Hodgkin and Non-Hodgkin lymphoma) • Endocrine pruritus (thyroid disease, uncontrolled diabetes) #Pruritus #Treatment #Algorithm #Hemodialysis #Uremic #Uremia #Management #Nephrology #CKD

Fatigue and IBD Algorithm • 40-50% patients have fatigue despite clinical remission • Risk factors: BMI, Depression, sleep disturbance, Female, Thiopurine, MTX?, Anemia • Prevalence Crohn's > UC Anemia and IBD Pearls: • IDA and active IBD: IV Fe > PO FE • Fe Carboxymaltose & Fe Sucrose > alt. IV FE formulations • If persistent macrocytosis after d/c IMM → consider NRH & Heme eval. re: BMBx • Supplement folate if on MTX or SSZ • Check Soluble Transferrin Receptor (sTfR) to differentiate IDA vs. ACD • Monitor & correct B12 (B12, MMA) for ileal Crohn's/resection/restricted diet/deficiency symptoms even if wnl B12 Patient Experience • 2/3 endorse persistent fatigue despite disease control • 1/3 have fatigue w/ active IBD and/or stress • Pts report dehydration as a factor • ~50% report no improvement despite attempted therapies • ~20% w/ improved fatigue after correction of lab abn./other causes • ~30% note improvement w/ mental health/Lifestyle/diet modifications Algorithm by Dr. Waseem Ahmed @Waseem_AhmedMD #Fatigue #IBD #Algorithm #diagnosis #management

$Refractory Ascites - Ascites that cannot be mobilized or early recurrence that cannot be prevented Diuretic Resistant:$

Refractory Ascites - Ascites that cannot be mobilized or early recurrence that cannot be prevented Diuretic Resistant: Lack of response to dietary Na restriction and maximal doses of diuretic Diuretic Intractable: Development of diuretic-induced complications Recurrent Ascites: Ascites that recurs at least on 3 occasions within a 12-month period despite dietary sodium restriction and adequate diuretic dosage Early Recurrence: Re-appearance of grade 2 or grade 3 ascites within 4 weeks of initial mobilization Lack of Response: Weight loss of <0.8 kg over 4 days, Urinary sodium < intake Maximum Doses of Diuretics: Spironolactone 400mg/day or amiloride 30mg/day, Furosemide 160mg/day - both for at least 1 week Diuretic-induced complications: • Renal: ↑Cr by > 100% or to >2.0 mg/dL • Na: ↓ by >10 mmol/L or to <125mmol/L • K: <3 mmol/L or >6 mmol/L • Hepatic encephalopathy #Refractory #Ascites #diagnosis #management #algorithm #treatment #hepatology

Gout - Diagnosis and Management Summary 3 Conditions for Gout to Manifest: 1. Hyperuricemia 2. Monosodium urate deposition in joints and/or soft tissues 3. A reaction to phagocytosed crystals that leads to an acute inflammatory response Risk Factors: • Advanced age • Male sex • Metabolic syndrome • Medications (diuretics) Epidemiology: • Men in 4th to 5th decade • Postmenopausal women Presentation: • Acute Intermittent Gout • Great toe (podagra): 50% of initial attacks • Other joints include forefoot, ankles, knees, fingers, wrist, elbow • Nocturnal onset → Peak 12-24 Hours • Fever, erythema, swelling, significant pain • Intercritical Gout: • Asymptomatic period between attacks • Chronic Recurrent Gout • Increasingly severe/frequent attacks • Arthritis may become persistent, polyarticular • Soft tissue involvement (cellulitis mimic, bursitis) • Chronic Tophaceous Gout • Chronic recurrent gout + tophi • Tophi on extensor elbows, Achilles tendon, fingers Synovial Fluid Testing: • WBCs >2000-100,000/μL • Neutrophil predominance • Urate crystal • Needle-shaped, negatively birefringent • Acute gout • Intracellular (leukocyte) crystals • Intercritical gout • Extracellular crystals • Gram stain and culture • Diagnose concomitant infection Serum Urate Levels: • Not helpful in acute gout • ↑ C-reactive protein, ESR, leukocytosis • Nonspecific findings Imaging: • Uncertain diagnosis or arthrocentesis not possible • Ultrasound → double contour sign • Dual-energy CT → MSU deposits • Plain films (chronic gout) → erosions with overhanging cortical bone Treatment: • Discontinue diuretics; consider losartan (uricosuric) • Weight loss, alcohol reduction • Specific dietary restrictions (insufficient evidence) • Acute gout treatment; consider comorbidities/drug interactions • Glucocorticoids (oral, intra-articular, or intramuscular) • NSAIDs • Low-dose colchicine Hyperuricemia: Allopurinol Therapy • First-line therapy • Decrease dosage in CKD • Indications • ≥2 attacks in a year • 1 attack + stage ≥3 CKD or nephrolithiasis, serum urate level >9 mg/dL • Tophi • +Radiographic signs of chronic gout • Concomitant low-dose colchicine, NSAIDs, or prednisone Hyperuricemia: Other Therapy • Febuxostat → patients intolerant of allopurinol; boxed warning • Probenecid → possibly combined with allopurinol • IV pegloticase → severe recurrent or tophaceous gout • Oral drug failure • Risk for severe allergic reactions • Serum urate level target <6 mg/dL #Gout #diagnosis #management #treatment #rheumatology