What is the most likely complication in an elderly patient with a history of hypertension (high blood pressure), presenting with extensive pruritis (itching), deteriorating kidney function, and refusing hospitalization, despite having normal labs except for impaired renal function?

Gouty Arthritis is the Most Likely Complication

In an elderly hypertensive patient with deteriorating renal function and severe pruritus, gouty arthritis (Option B) represents the most likely complication because declining GFR directly impairs uric acid clearance, creating hyperuricemia that precipitates gout, especially when combined with untreated hypertension. 1

Pathophysiological Rationale

The clinical scenario describes a perfect storm for gouty arthritis development:

• Declining renal function proportionally decreases uric acid clearance, leading to progressive hyperuricemia as GFR falls 1
• Untreated hypertension creates a synergistic effect with CKD progression, accelerating both renal deterioration and uric acid accumulation 1, 2
• The combination of untreated hypertension and deteriorating renal function creates the ideal metabolic environment for gouty arthritis to develop 1

Why Pruritus Supports This Diagnosis

While pruritus is the presenting symptom, it serves as a marker of advanced CKD rather than a competing diagnosis:

• Pruritus occurs in 42-65% of patients with advanced renal dysfunction and is a hallmark symptom of CKD/ESRD 1, 3
• The extensive scratch marks indicate severe, chronic pruritus consistent with significant renal impairment 4
• Pruritus severity correlates with worsening kidney function, suggesting this patient has substantial GFR decline 3

Why Other Options Are Less Likely

Renal cell carcinoma (Option A) is not a complication of CKD itself but rather a separate malignancy that could coincidentally occur. While one case report describes crescentic glomerulonephritis with renal cell carcinoma 5, this represents an extremely rare association, not a typical complication of hypertensive nephropathy with declining function.

Myelodysplastic syndrome (Option C) has no established pathophysiological link to hypertensive CKD or declining renal function. This would be a coincidental finding rather than a complication of the patient's renal condition.

Clinical Management Priorities

Given this patient's refusal of hospitalization, outpatient management should focus on:

• Check serum uric acid levels immediately to confirm hyperuricemia and quantify gout risk 1
• Evaluate severity of renal dysfunction with creatinine and eGFR to determine urgency of intervention 1
• Initiate blood pressure control despite patient reluctance, as this is essential to slow further renal deterioration 1
• Avoid nephrotoxic medications, particularly NSAIDs, which could precipitate acute-on-chronic kidney injury 1

Critical Caveat

This patient's refusal of hospitalization is concerning given the deteriorating kidney function. If creatinine exceeds 5 mg/dL (500 μmol/L), dialysis evaluation becomes urgent regardless of patient preference 1. The extensive pruritus itself indicates advanced disease that may require renal replacement therapy, as inadequate dialysis worsens pruritus 1.