What is the best course of action for a 67-year-old African-American female patient in severe hypertensive crisis (blood pressure 220/120 mmHg and 244/146 mmHg), with impaired renal function (eGFR 13), anemia (hemoglobin 3.7), and significant proteinuria (urine albumin >239), currently on clonidine (0.2 mg 24-hour patch), carvedilol (25 mg twice a day), and amlodipine (10 mg daily), who has discontinued losartan (50 mg) due to concerns about hair loss?

Management of Hypertensive Crisis in a 67-Year-Old African-American Female with Severe Renal Impairment

This patient requires immediate hospitalization for management of hypertensive emergency with evidence of end-organ damage (severe renal impairment) and should be started on intravenous antihypertensive therapy with careful blood pressure reduction targeting no more than 20-25% decrease in mean arterial pressure over several hours.

Patient Assessment and Classification

This 67-year-old African-American female presents with:

• Severe hypertension: BP 220/120 mmHg (manual) and 244/146 mmHg (electronic)
• Evidence of end-organ damage:
  • Severe renal impairment (eGFR 13)
  • Significant proteinuria (urine albumin >239, urine protein 540)
  • Anemia (Hgb 3.7)
• Current medications:
  • Clonidine 0.2 mg 24-hour patch
  • Carvedilol 25 mg twice daily
  • Amlodipine 60 mg daily (likely 10 mg based on standard dosing)
  • Discontinued losartan 50 mg due to perceived hair loss

This presentation meets criteria for hypertensive emergency due to the combination of severely elevated blood pressure with evidence of end-organ damage, specifically renal failure 1.

Immediate Management

1. Hospital admission is necessary, preferably to an intensive care unit for close monitoring
2. Initiate IV antihypertensive therapy with careful BP monitoring
   • Recommended agents include:
     • Nicardipine (preferred due to renal impairment)
     • Clevidipine
     • Labetalol (use with caution as patient is already on carvedilol)
3. Target blood pressure reduction: Lower mean arterial pressure by 20-25% over several hours 1
   • Avoid aggressive BP lowering which can worsen organ perfusion
   • Initial target: Reduce BP to approximately 180/100 mmHg

Diagnostic Workup

Immediate diagnostic testing should include:

• Complete blood count (already shows anemia)
• Comprehensive metabolic panel
• Urinalysis with microscopic examination (to assess for casts, RBCs)
• ECG (to assess for left ventricular hypertrophy or ischemia)
• Chest X-ray (to evaluate for pulmonary edema)
• Fundoscopic examination (to assess for hypertensive retinopathy)
• Consider renal ultrasound to evaluate kidney size and rule out obstruction

Subsequent Management

After initial stabilization:

1. Transition to oral therapy once BP is controlled and stable
2. Optimize antihypertensive regimen:
   • Continue amlodipine (dihydropyridine CCB)
   • Consider replacing clonidine (should be avoided in heart failure) 1
   • Maintain beta-blocker therapy (carvedilol has proven benefits in heart failure) 1
   • Reinstitute ARB therapy despite patient concerns about hair loss, as ARBs are specifically indicated for diabetic nephropathy and proteinuria 2, 3, 4
   • Add a thiazide-like diuretic if volume overload is present 5

Special Considerations

1. Renal protection: ARB therapy is critical given the patient's severe renal impairment and proteinuria. Losartan or another ARB should be reintroduced with patient education about its benefits for renal protection 2.

2. Medication adherence: Address the patient's concern about hair loss with losartan, as this is not a common side effect. Poor adherence may have contributed to this hypertensive crisis.

3. Blood pressure targets: For this patient with severe renal disease, target BP should be <130/80 mmHg once stabilized 5.

4. Nephrology consultation: Given the severity of renal impairment (eGFR 13), nephrology consultation is essential to evaluate for potential need for renal replacement therapy.

5. Anemia management: The patient's severe anemia (Hgb 3.7) requires urgent evaluation and may necessitate blood transfusion depending on symptoms and hemodynamic stability.

Follow-up Plan

1. Close monitoring of renal function and electrolytes during BP reduction
2. Nephrology follow-up within 1 week of discharge
3. Cardiology follow-up within 2 weeks
4. Primary care follow-up within 1 week of discharge
5. Medication adherence counseling and education

Common Pitfalls to Avoid

1. Overly aggressive BP reduction - can lead to organ hypoperfusion and worsen renal function
2. Using oral medications for initial management - IV therapy is required for hypertensive emergency
3. Discontinuing all previous antihypertensives - maintain effective agents while adding new ones
4. Failing to address medication adherence - critical to prevent recurrence
5. Neglecting renal protection - ARB therapy is essential despite patient concerns