A 65-year-old female with intermittent leg swelling, impaired renal function, and hypertension on telmisartan, amlodipine, atorvastatin, and clopidogrel - what's the next step?

Management of Hypertension with Worsening Renal Function in a 65-Year-Old Female

The most appropriate next step is to discontinue telmisartan and replace it with a non-RAAS blocking agent like a calcium channel blocker or diuretic, as the doubling of serum creatinine from 0.8 to 1.6 mg/dL while on an ARB strongly suggests renovascular disease that requires immediate intervention. 1

Evaluation of Worsening Renal Function

The patient presents with:

• Significant rise in serum creatinine (from 0.8 to 1.6 mg/dL in 4 months)
• Intermittent leg swelling
• Uncontrolled hypertension (150/60 mmHg) despite multiple medications
• Current medications: telmisartan 40 mg, amlodipine 5 mg, atorvastatin 10 mg, clopidogrel 75 mg

This clinical picture strongly suggests:

1. Possible renovascular hypertension: The combination of resistant hypertension, worsening renal function, and leg swelling in an elderly patient is highly suspicious for renal artery stenosis 1

2. ARB-induced renal dysfunction: The doubling of serum creatinine while on telmisartan is concerning, as ARBs can cause significant renal deterioration in patients with bilateral renal artery stenosis or in patients with advanced renal disease 1

Immediate Management Steps

1. Discontinue telmisartan: When serum creatinine rises significantly (doubling from baseline) in a patient on an ARB, the medication should be discontinued immediately 1, 2

2. Replace with alternative antihypertensive: Consider increasing amlodipine to 10 mg or adding a thiazide diuretic 1

3. Evaluate for renovascular disease:

   • Duplex ultrasound of renal arteries (first-line imaging) 1
   • If DUS is inconclusive or positive, proceed to MRA or CTA 1

Diagnostic Workup

• Renal function assessment:

  • Calculate eGFR using CKD-EPI formula 1, 3
  • Check urine albumin-to-creatinine ratio to assess for proteinuria 3
  • Monitor electrolytes, particularly potassium levels 2

• Screening for renovascular disease:

  • Duplex ultrasound criteria: Peak systolic velocity ≥200 cm/s, renal-aortic ratio >3.5 1
  • Look for kidney size discrepancy or cortical thinning 1

Treatment Algorithm

1. If renovascular disease is confirmed:

   • Continue withholding RAAS blockers (ACEi/ARBs)
   • Optimize BP control with calcium channel blockers and/or diuretics
   • Consider renal artery revascularization if: 1
     • Refractory hypertension persists
     • Progressive decline in renal function continues
     • Flash pulmonary edema occurs

2. If renovascular disease is ruled out:

   • Consider other causes of worsening renal function:
     • Medication-induced nephrotoxicity (NSAIDs, contrast)
     • Volume depletion
     • Urinary tract obstruction
     • Primary kidney disease

Medication Adjustments

• Amlodipine: Can be safely used in renal dysfunction and may be increased to 10 mg daily 4
• Diuretic consideration: Add a thiazide diuretic if volume overload is present 1
• Clopidogrel: Continue as prescribed, especially if patient has vascular disease 1
• Atorvastatin: Continue as prescribed

Follow-up Monitoring

• Recheck serum creatinine within 1-2 weeks after discontinuing telmisartan
• Monitor blood pressure closely (target <140/90 mmHg) 1
• If renal function improves after ARB discontinuation, this further supports renovascular disease as the underlying cause

Important Considerations

• Age factor: At 65 years, this patient has higher risk for atherosclerotic renal artery stenosis 1
• Leg swelling: May be related to calcium channel blocker (amlodipine) side effect, venous insufficiency, or heart failure 5
• Pulse pressure: Wide pulse pressure (150/60 mmHg) suggests arterial stiffness, common in elderly hypertensive patients 1

The combination of worsening renal function with ARB therapy strongly suggests renovascular disease until proven otherwise, and immediate discontinuation of telmisartan is warranted to prevent further kidney damage.