Diagnostic Workup for Hypertensive Emergency in CKD Stage III
This patient requires immediate brain imaging (CT or MRI with FLAIR) to exclude intracranial hemorrhage and confirm hypertensive encephalopathy/posterior reversible encephalopathy syndrome (PRES), as severe hypertension with headache, vomiting, and dizziness constitutes a hypertensive emergency with neurological symptoms. 1
Immediate Critical Diagnostics
Brain imaging must not be delayed when hypertensive encephalopathy is suspected, as focal neurological lesions are rare in hypertensive encephalopathy and should raise suspicion for intracranial hemorrhage requiring immediate identification. 1
Essential Laboratory Tests
Complete blood count with hemoglobin and platelet count to assess for thrombotic microangiopathy (TMA), which can complicate malignant hypertension 1
Serum creatinine and electrolytes (sodium, potassium) are critical as acute kidney injury superimposed on baseline CKD stage III dramatically worsens prognosis 1
Calculate eGFR using the race-free CKD-EPI equation from serum creatinine, as creatinine alone may underestimate renal dysfunction, especially in women and those with low muscle mass 1
Serum potassium is particularly critical as hyperkalemia risk increases with CKD and many antihypertensive medications (ACE inhibitors, ARBs, diuretics) 1
Cardiac Evaluation
12-lead ECG to detect ischemia, arrhythmias, and left ventricular hypertrophy 1
Measure BP in both arms and lower limb to detect pressure differences from aortic dissection, which requires different management 1
Troponin-T, CK, CK-MB if cardiac symptoms are present to exclude acute coronary syndrome 1
Point-of-care cardiac ultrasound or transthoracic echocardiography to assess cardiac structure, function, and pulmonary edema 1
Additional Testing if Microangiopathic Hemolysis Suspected
- Peripheral blood smear for schistocyte assessment and ADAMTS13 activity levels to distinguish TTP from hypertension-induced TMA 1
Renal-Specific Monitoring
- Urine albumin-to-creatinine ratio provides independent prognostic information beyond creatinine alone 1
Critical Pitfalls to Avoid
Do not assume normal kidney function based on "normal" creatinine alone—always calculate eGFR as creatinine may underestimate renal dysfunction. 1
Do not delay brain imaging while waiting for other test results when neurological symptoms are present with severe hypertension. 1