고혈압과 azotemia 를 동반한 68 세 남자 환자 Department of Nephrology Prof. 임천규 /R3 권성진

박 O 우 (M/68) Adm : Chief complaint Fatigue o/s) 3 weeks ago Chief complaint Fatigue o/s) 3 weeks ago Present illness Present illness - 수년전부터 고혈압 병력 있었으나 특별한 치료 없이 지내던 환자로 내원 3 주전부터 fatigue, anorexia 발생하여 개인병원 방문후 creatinine 상승 소견 보여 further evaluation 위해 입원 - 수년전부터 고혈압 병력 있었으나 특별한 치료 없이 지내던 환자로 내원 3 주전부터 fatigue, anorexia 발생하여 개인병원 방문후 creatinine 상승 소견 보여 further evaluation 위해 입원

 Past medical history DM / HTN / Hepatitis / TB (-/+/-/+) : no medication Drug Hx (-) Op Hx (-) Family history Family historyunremarkable Personal history Personal history Alcohol (+) : 소주 1 병 /d weekly Smoking (+) : 1 pack/d x 40 years

Review of Systems General: fatigue(+) sweating(-) polydipsia(-) wt loss(-)  General: fatigue(+) sweating(-) polydipsia(-) wt loss(-)  H & Neck: headache(-) stiffness(-)  Respiratory : cough(-) sputum(-) dyspnea(-)  Cardiac: chest pain(-) orthopnea(-) palpitation(-)  GI: anorexia(+) nausea(-) vomiting(-) diarrhea(-)  Urinary: dysuria(-) nocturia(-) frequency(-)  Musculoskeletal : numbness(-) pain(-)

Physical Examination Vital sign: 180/90 mmHg – 78 회 /min – 20 회 /min – 36.5 °C Vital sign: 180/90 mmHg – 78 회 /min – 20 회 /min – 36.5 °C B.W : 62kg Ht. : 172cm BMI 21.0 kg/m 2 B.W : 62kg Ht. : 172cm BMI 21.0 kg/m 2 General appearance General appearance - Alert mentality - Acute ill-looking appearance Head & Neck Head & Neck - No neck vein engorgement - No palpable cervical mass Chest - Clear breath sound without crackle or wheezing Chest - Clear breath sound without crackle or wheezing - Regular heart beats without murmur - Regular heart beats without murmur

Physical Examination Abdomen Abdomen - Soft and flat abdomen - Tenderness / Rebound tenderness (-/-) - Tenderness / Rebound tenderness (-/-) - No palpable abdominal mass - No palpable abdominal mass - Abdominal bruit (+) : Rt Back & Extremity Back & Extremity - CVA Tenderness (-/-) - Pretibial pitting edema (-/-) - Pretibial pitting edema (-/-) Neurology Neurology - Motor, sensory : intact - Babinski (-/-)

Initial Lab Finding ( ) CBC/DC 8600/mm3 –13.2 g/dl – 38.7 % /mm³ ( seg. 61.3%) 8600/mm3 –13.2 g/dl – 38.7 % /mm³ ( seg. 61.3%) INR : 1.0 % aPTT : 34.5 sec INR : 1.0 % aPTT : 34.5 secChemistry T-chol/TG210/349 mg/dL T-chol/TG210/349 mg/dL TB/DB0.7/0.1 mg/dL TB/DB0.7/0.1 mg/dL T-protein/albumin8.1/4.0 g/dL T-protein/albumin8.1/4.0 g/dL AST/ALT24/26 U/L AST/ALT24/26 U/L ALP/GGT102/18 U/L ALP/GGT102/18 U/L BUN/Cr31/2.0 mg/dL BUN/Cr31/2.0 mg/dL Na/K/Cl135/4.3/96 mmol/L Na/K/Cl135/4.3/96 mmol/L Ca/P/Mg 9.4/4.4/2.4 mg/dL Ca/P/Mg 9.4/4.4/2.4 mg/dL CRP<0.5 mg/dL CRP<0.5 mg/dLU/A RBC 0~1/HPFWBC 0~1/HPF RBC 0~1/HPFWBC 0~1/HPF SG : PH : 6.5 protein(-) glucose(-) SG : PH : 6.5 protein(-) glucose(-)

Chest X-Ray ( )

Initial Problem List 1. HTN 2. Fatigue 3. Elevated creatinine 4. Hypercholesterolemia 5. Abdominal bruit

Initial Assessment #1. Renal insufficiency d/t renovascular HTN : Unilateral renal artery stenosis R/o bilateral renal a. stenosis R/o bilateral renal a. stenosis R/o vasculitis R/o vasculitis R/o hypertensive CRF R/o hypertensive CRF

Diagnostic Plan 1. Abdominal US 2. Renal Duplex Doppler US 3. Captopril renal scan 4. Plasma renin activity test 5. Renal angiography HR urine collection 7. Serologic test for vasculitis

Therapeutic Plan 1. BP medication : ACEi/ARB, CCB, b-blocker 2. Treatment of Atherosclerosis : aspirin, statin 3. If renal artery stenosis is present and positive captopril renogram, angioplasty with stent insertion 4. Surgical intervention

Lab Finding Viral marker HBs Ag (-)Anti-HCV (-) HBs Ab (-) Anti-HIV (-) Hbc Ab (-) VDRL (-) 24hr urine collection protein 153mg/d creatinine 1088mg/d CrCl = 37.8ml/min PRA>20 ng/ml/hr (0.8~1.36) Serum Aldosterone150 pg/ml (50~194)

Lab Finding Serologic marker IgG1910 mg/dL (694~1618)C3 135 mg/dL (88~201) IgA 245 mg/dL (68~378)C4 20 mg/dL (15~45) IgM194 mg/dL (60~263) IgE2200 IU/ml (<100) ANA(Qual) nucleolarRF < 20 IU/ml (<20) C-ANCA negative P-ANCA negative Anti ds-DNA abnegative Anti phospho IgM9.14 MPL/ml (<10) Anti phospho IgG 4.97 GPL/ml (<10) Anti Sm-Abnegative

Abdominal US ( )

Renal Doppler US ( )

DTPA Captopril Renal Scan ( )

Renal Angiography ( )

F/U Renal Doppler US ( )

F/U DTPA Captopril Scan ( )

Angioplasty 9/24 : Cr /2 : Cr 1.9 Clinical Course (1)

Clinical Course (2) Losartan 50mg Felodipine 5mg Atenolol 50mg Thiazide 12.5mg Aspirin 100mg Atorvastatin 10mg Irbesartan 75mg Felodipine 5mg Atenolol 50mg+Thiazide 12.5mg

F/U Renal Doppler US (04-3-8)

Clinical Course (3) Aspirin 100mg Atorvastatin 10mg Irbesartan 75mg Felodipine 5mg Atenolol 50mg + Thiazide 12.5mg

F/U Renal Doppler US ( )

Clinical Course (4) Creatinine (mg/dL) BP (mmHg) 135/80120/70115/60125/70120/65145/85 Aspirin 100mg EOD Warfarin 2mg Atorvastatin 10mg Efonidipine 40mg Atenolol 50mg + Thiazide 12.5mg Aspirin 100mg EOD Warfarin 1mg Simvarstatin 20mg Efonidipine 40mg Irbesartan 75mg