eMedicine Specialties > Nephrology > Hypertension and the Kidney

Hypertension, Malignant: Differential Diagnoses & Workup

Author: John D Bisognano, MD, PhD, FACP, FACC, Associate Professor, Director of Outpatient Cardiology, Department of Medicine, Cardiology Division, University of Rochester Medical Center
Contributor Information and Disclosures

Updated: Sep 15, 2009

Differential Diagnoses

Acute Renal Failure
Hyperthyroidism
Aortic Coarctation
Pheochromocytoma
Aortic Dissection
Renal Artery Stenosis
Chronic Renal Failure
Subarachnoid Hemorrhage
Eclampsia
Hypercalcemia

Other Problems to Be Considered

Stroke
Intracranial mass
Head injury
Epilepsy or postictal state
Connective-tissue disease (especially lupus with cerebral vasculitis)
Drug overdose or withdrawal
Cocaine or amphetamine ingestion
Acute anxiety
Thrombotic thrombocytopenic purpura5

Workup

Laboratory Studies

  • Initial laboratory studies include CBC count and electrolytes, including calcium, BUN, creatinine, glucose, coagulation profile, and urinalysis.
  • Other laboratory studies are indicated only as directed by the initial workup. This may include cardiac enzymes, urinary catecholamines, thyroid-stimulating hormone (TSH), and 24-hour urine collection for vanillylmandelic acid (VMA) and catecholamines.
  • Renal function should be evaluated through urinalysis, complete chemistry profile, and CBC count. Expected findings include elevated BUN and creatinine, hyperphosphatemia, hyperkalemia or hypokalemia, glucose abnormalities, acidosis, hypernatremia, and evidence of microangiopathic hemolytic anemia. Urinalysis may reveal proteinuria, microscopic hematuria, and red blood cell or hyaline casts.
  • In patients with hyperaldosteronism (a secondary cause of hypertension), aldosterone promotes renal potassium wasting, resulting in low serum potassium.

Imaging Studies

  • Routine screening consists of a chest radiograph. The chest radiograph is useful for assessment of cardiac enlargement, pulmonary edema, or involvement of other thoracic structures, such as rib notching with aortic coarctation or a widened mediastinum with aortic dissection.
  • Other tests, such as head CT scan, transesophageal echocardiogram, and renal angiography, are indicated only as directed by the initial workup.

Other Tests

  • An ECG is an essential part of the evaluation. The ECG is necessary to screen for ischemia, infarct, or evidence of electrolyte abnormalities or drug overdose.

Procedures

  • No procedures are performed routinely for the evaluation of malignant hypertension.

More on Hypertension, Malignant

Overview: Hypertension, Malignant
Differential Diagnoses & Workup: Hypertension, Malignant
Treatment & Medication: Hypertension, Malignant
Follow-up: Hypertension, Malignant
Multimedia: Hypertension, Malignant
References
Further Reading
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References

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Further Reading

Related eMedicine topics:
Encephalopathy, Hypertensive
Hypertension [Nephrology]
Hypertension [Ophthalmology]
Hypertension [Pediatrics: Cardiac Disease and Critical Care Medicine]
Hypertensive Emergencies
Ocular Hypertension
Papilledema
Pseudopapilledema

Clinical guidelines:
ACR Appropriateness Criteria® renovascular hypertension. American College of Radiology - Medical Specialty Society. 1995 (revised 2007). 9 pages. NGC:006003

American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of hypertension. American Association of Clinical Endocrinologists - Medical Specialty Society. 2006 Mar-Apr. 30 pages. NGC:005007

Clinical trials:
Single Incision Laparoscopy (SIL)

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Keywords

malignant hypertension, hypertensive emergency, hypertension, high blood pressure, metoprolol, verapamil, diltiazem, labetalol, papilledema, hydralazine, nitroprusside, hypertensive, hypertensive urgency, phentolamine, hypertensive encephalopathy, accelerated hypertension, fibrinoid necrosis of arterioles and small arteries, microangiopathic hemolytic anemia, elevated blood pressure

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Contributor Information and Disclosures

Author

John D Bisognano, MD, PhD, FACP, FACC, Associate Professor, Director of Outpatient Cardiology, Department of Medicine, Cardiology Division, University of Rochester Medical Center
John D Bisognano, MD, PhD, FACP, FACC is a member of the following medical societies: American College of Cardiology and American College of Physicians-American Society of Internal Medicine
Disclosure: Nothing to disclose.

Medical Editor

L Michael Prisant, MD, FACC, Director of Hypertension and Clinical Pharmacology Unit, Professor of Medicine, Department of Medicine, Medical College of Georgia
L Michael Prisant, MD, FACC is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Clinical Pharmacology, American College of Forensic Examiners, American College of Physicians, American Heart Association, and American Medical Association
Disclosure: Abbott Grant/research funds Investigator; Boehringer-Ingelheim Grant/research funds Other; Eli Lilly None Investigator; Novartis None Investigator; Abbott, Boehringer-Ingelheim, Forest, Gilead, Merck, Merck/Schering-Plough, Novartis, Oscient, Sciele, SunTech Medical Consulting fee Consulting; Abbott, Boehringer-Ingelheim, Merck, Merck/Schering-Plough, Novartis, Oscient Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

George R Aronoff, MD, Director, Professor, Departments of Internal Medicine and Pharmacology, Section of Nephrology, Kidney Disease Program, University of Louisville School of Medicine
George R Aronoff, MD is a member of the following medical societies: American Federation for Medical Research, American Society of Nephrology, Kentucky Medical Association, and National Kidney Foundation
Disclosure: Nothing to disclose.

CME Editor

Rebecca J Schmidt, DO, FACP, FASN, Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine
Rebecca J Schmidt, DO, FACP, FASN is a member of the following medical societies: American College of Osteopathic Internists, American College of Physicians, American Medical Association, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation, Renal Physicians Association, and West Virginia State Medical Association
Disclosure: Abbott Grant/research funds Speaking and teaching; Genzyme Honoraria Consulting; Amgen Honoraria Speaking and teaching; Ortho Biotech Honoraria Speaking and teaching

Chief Editor

Vecihi Batuman, MD, FACP, FASN, Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System
Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology
Disclosure: Nothing to disclose.

 
 
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