Morning Quiz ☕️ 

A 65-year-old woman presents for a follow-up examination after two previous elevated blood pressure readings:

• 175/105 mm Hg (1 week ago)

• 185/110 mm Hg (3 weeks ago)

She has a history of well-controlled type 2 diabetes mellitus.

• Current BP: 175/110 mm Hg

• Physical examination: No other abnormalities noted.

Clinical Course

• Antihypertensive therapy is started, but BP remains elevated at the next visit (3 weeks later).

Laboratory & Imaging Findings

• Increased plasma renin activity

• Normal: Erythrocyte sedimentation rate (ESR), serum electrolytes

• Angiography:

  • High-grade stenosis of the proximal right renal artery

  • Left renal artery appears normal

Question

Which of the following is the most likely diagnosis?

Options

A. Atherosclerosis
B. Congenital renal artery hypoplasia
C. Fibromuscular dysplasia
D. Takayasu arteritis
E. Temporal arteritis

Correct Answer 🎯: A. Atherosclerosis

1. 65-year-old woman with diabetes → High-risk profile for atherosclerosis.

2. Proximal renal artery stenosis on angiography → Classic location for atherosclerotic stenosis (vs. fibromuscular dysplasia, which is mid-distal).

⚙️

Atherosclerosis Risk Factors (Age 65 + Diabetes)
⬇
Plaque Accumulation in Proximal Renal Artery
(Key: Atherosclerosis favors ostium/proximal segments)
⬇
High-Grade Stenosis (↓ Renal Blood Flow)

⬇
Ischemic Kidney (Right) → Juxtaglomerular Cell Activation
⬇
Renin Release ↑
⬇
Angiotensinogen → Angiotensin I (via Renin)
⬇
ACE Converts Ang I → Ang II
⬇
Angiotensin II Effects:

• Vasoconstriction (Systemic HTN) → BP ↑ (175/110 mmHg)

• Aldosterone Release (Na+/H2O Retention) → Further BP ↑
  ⬇
  Persistent HTN Despite Therapy (Unilateral stenosis → contralateral kidney compensates poorly)
  ⬇
  Lab Findings:

• Plasma Renin Activity ↑ (Due to hypoperfusion)

• Normal ESR/Electrolytes (No inflammation/electrolyte imbalance)
  ⬇
  Angiography:

• Proximal Stenosis (Right Renal Artery) → Atherosclerosis Classic

• Left Renal Artery Normal → Rules out bilateral causes (e.g., vasculitis)

Differential Table ⚖️

Visual Cheat Chart 📈 

Practice Questions ⏳️ 

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Dr. Shoaib Ahmad