What is the best next step for a patient with uncontrolled hypertension, impaired renal function (estimated GFR of 30), and non-adherence to their current medication regimen of amlodipine (calcium channel blocker), losartan (angiotensin II receptor blocker), and hydrochlorothiazide (thiazide diuretic)?

Management of Hypertensive Emergency with Renal Insufficiency

The best next step for this patient is to resume medications but change hydrochlorothiazide to a longer-acting agent (option B).

Assessment of Current Situation

This patient presents with:

• Severe hypertension (210/105 mmHg)
• Renal insufficiency (eGFR 30)
• Mild pedal edema (1+)
• Current medications: amlodipine, losartan, hydrochlorothiazide
• Poor medication adherence
• No symptoms of end-organ damage (no chest pain or shortness of breath)

Management Decision Algorithm

1. Determine if this is a hypertensive emergency requiring immediate hospitalization:

   • BP >180/120 mmHg WITH evidence of acute end-organ damage → ICU admission
   • BP >180/120 mmHg WITHOUT evidence of acute end-organ damage → Outpatient management possible

2. For this patient without signs of acute end-organ damage:

   • Resume antihypertensive medications with appropriate adjustments
   • Modify regimen based on renal function
   • Address medication adherence

Rationale for Management Decision

The International Society of Hypertension guidelines recommend outpatient management for asymptomatic patients with severe hypertension who don't have evidence of acute end-organ damage 1. Since this patient is feeling well with no chest pain or shortness of breath, immediate hospitalization is not necessary.

The patient's current regimen includes:

• Amlodipine (calcium channel blocker) - appropriate for CKD
• Losartan (ARB) - appropriate for CKD
• Hydrochlorothiazide (thiazide diuretic) - less effective with eGFR <30

With an eGFR of 30, hydrochlorothiazide is less effective and should be replaced with a longer-acting agent 2. The European Society of Cardiology recommends switching to a longer-acting thiazide-like diuretic such as chlorthalidone or indapamide for patients with renal insufficiency 2.

Medication Adjustments

1. Resume amlodipine and losartan - Both are effective and safe in patients with renal dysfunction 3, 4
2. Replace hydrochlorothiazide with a longer-acting thiazide-like diuretic:
   • Chlorthalidone (12.5-25 mg daily) or
   • Indapamide (1.25-2.5 mg daily) 2

Addressing Medication Non-Adherence

Poor medication adherence is a major contributor to uncontrolled hypertension 5. Strategies to improve adherence include:

• Simplify regimen: Consider fixed-dose combinations where available 2
• Patient education: Discuss the importance of medication adherence and consequences of uncontrolled hypertension
• Address medication concerns: Patients with higher medication concern beliefs are more likely to be non-adherent 6
• Consider electronic monitoring: This can improve adherence and prevent unnecessary treatment escalation 7

Follow-up Plan

• Schedule follow-up within 2-4 weeks to assess BP response
• Monitor renal function and electrolytes within 1-2 weeks after medication changes
• Target BP <140/90 mmHg initially, with potential for more aggressive targets if tolerated
• Check standing BP to assess for orthostatic hypotension 2

Why Other Options Are Not Preferred

• Option A (ICU admission with nitroprusside): Too aggressive for a patient without signs of end-organ damage
• Option C (sublingual nifedipine): Not recommended due to risk of unpredictable hypotension
• Option D (nephrology referral for dialysis): Premature without first optimizing medical management; eGFR of 30 does not necessarily require immediate dialysis

By resuming medications with appropriate adjustments for renal function, we can effectively manage this patient's hypertension while addressing the underlying issue of medication non-adherence.