Renal diseases and blood pressure dysregulation in acute care: Pathophysiology, clinical patterns

Table 1 Blood pressure phenotypes, mechanisms, and emergency department management in renal diseases

Renal disease	BP phenotype	Key pathophysiology	ED diagnostic clues	Immediate ED management	Ref.
CKD	Persistent HTN (± refractory)	Na+/water retention; RAAS activation	Known CKD, Cr (increase), anemia	Gradual BP reduction (≤ 25%); start IV CCB (nicardipine); avoid overcorrection	Dylewska et al[4], Jeon et al[7], Nakazawa et al[43]
AKI	Variable: HTN or hypotension	Volume overload or hypoperfusion	Rapid Cr (increase), oliguria	Treat cause: Fluids (if hypovolemic) or diuretics; avoid nephrotoxins	Yu et al[2], Lehman et al[3], Badin et al[13]
GN	Severe HTN	Inflammation + RAAS activation	Hematuria, proteinuria, edema	IV antihypertensives; consider immunologic workup	Ihm[25], Tizki et al[26]
Nephrotic syndrome	Mild-moderate HTN	Hypoalbuminemia to edema	Massive proteinuria, edema	Diuretics; cautious BP control	Bovée et al[18], Pugh et al[19], Ihm[25], Kidney Disease: Improving Global Outcomes (KDIGO) Glomerular Diseases Work Group[27]
RAS	Resistant HTN	Renal ischemia to RAAS overactivation	Abdominal bruit, flash pulmonary edema	Avoid ACEI if bilateral; imaging referral	Shen et al[38]
Uremia (ESRD)	Severe HTN or hypotension	Toxin accumulation	Uremic symptoms	Urgent dialysis indication	Lacson and Lazarus[6], Davenport[20], Flythe and Bansal[21]
Obstructive uropathy	HTN (early) to hypotension (late)	Back pressure + renal dysfunction	Hydronephrosis (US)	Relieve obstruction (catheter, stent)	Kittanamongkolchai et al[41], Chalisey and Karim[42]
Sepsis-associated AKI	Hypotension	Vasodilation + capillary leak	Infection signs, lactate (increase)	Early fluids + vasopressors	Tsuchida et al[35]

RAAS: Renin-angiotensin-aldosterone system; CKD: Chronic kidney disease; ESRD: End-stage renal disease; HTN: Hypertension; AKI: Acute kidney injury; ED: Emergency department; CCB: Calcium channel blocker; BP: Blood pressure; GN: Glomerulonephritis; ACEI: Angiotensin converting enzyme inhibitors; US: Ultrasonographic.