Clinical Commander

All dossiers
renal.hypertensive-nephrosclerosis.v1

Hypertensive Nephrosclerosis (HTN-CKD)

nephrologychronicacuteadultoutpatientinpatient
Start encounter →Print handoutPRODUCTION

Promoted to INTEGRATED 2026-05-22 (shard-4 build campaign): added registry-resolving workups (secondary_htn, aki_on_ckd); every evidence.pmid re-sourced and live-verified via PubMed; every regimen RxCUI reverse-looked-up live at RxNav. Hypertensive nephrosclerosis: intensive BP control to KDIGO 2021/SPRINT targets with ACEi/ARB first-line (AASK), diuretic + CCB + add-ons, SGLT2i for proteinuric CKD; APOL1-associated risk; malignant-HTN escalation pathway. PMID anchors (live-verified PubMed 2026-05-22): 12435255 AASK, 26551272 SPRINT, 33637192 KDIGO 2021 BP-CKD, 38490803 KDIGO 2024 CKD, 36331190 EMPA-KIDNEY. Prior fabricated PMIDs removed. RxCUI corrections (reverse-verified at RxNav): metolazone 6916, chlorthalidone 2409, losartan 52175, dapagliflozin 1488564, finerenone 2562811 (prior 4603/5487/83515/1486436/2390006 were wrong-drug or invalid). Sibling routing: neph.ckd.core.v1, renal.ckd-progression.v1.

Entry points (6)

  • lab_abnormality
    Declining eGFR in long-standing HTN patient ± modest albuminuria (KDIGO 2012 CKD)
    declining_egfr_in_htn_patient
  • lab_abnormality
    Persistent UACR 30-300 + chronic HTN (no diabetes) — hypertensive CKD phenotype (KDIGO 2012 CKD)
    persistent_modest_albuminuria_htn
  • history
    Long-standing uncontrolled HTN ≥10 yrs (KDIGO 2012 CKD; AHA 2017)
    long_standing_uncontrolled_htn
  • history
    African-ancestry patient with HTN-CKD — APOL1 high-risk substrate evaluation
    african_ancestry_apol1_substrate
  • symptom
    BP >180/120 + new AKI + retinopathy (grade III/IV) ± TMA — malignant HTN nephrosclerosis (AHA 2017; KDIGO 2012 CKD)
    malignant_htn_aki_retinopathy
  • imaging
    Asymmetric kidneys + flash pulm edema or refractory HTN — ischemic atherosclerotic RAS suspicion (ASTRAL/CORAL)
    asymmetric_kidneys_renovascular

Required inputs (14)

  • agerequired
    demographic • used at CONTEXT
    Age + ancestry stratify APOL1 + FMD vs atherosclerotic RAS probability
  • sexrequired
    demographic • used at CONTEXT
    FMD predominantly young women; atherosclerotic RAS older male smokers
  • creatininerequired
    lab • used at CONTEXT
    eGFR core input — KDIGO staging G1-G5 (KDIGO 2012 CKD)
  • uacrrequired
    lab • used at CONTEXT
    A1/A2/A3 sub-staging — HTN-CKD typically A1-A2; A3 (>300) suggests overlap with diabetic / glomerular / APOL1-FSGS (KDIGO 2012 CKD)
  • potassiumrequired
    lab • used at CONTEXT
    ACEi/ARB + finerenone + spironolactone tolerability monitoring (KDIGO 2024 CKD)
  • urinalysisrequired
    lab • used at INITIAL_WORKUP
    Bland sediment expected in pure HTN-CKD; active sediment → biopsy for GN overlap (KDIGO 2012 CKD)
  • sbprequired
    vital • used at CONTEXT
    BP target <120/80 SPRINT-driven for CKD-non-DM; <130/80 for DKD overlap (SPRINT NEJM 2015; KDIGO 2024)
  • dbprequired
    vital • used at CONTEXT
    DBP component; malignant HTN if DBP >120
  • diabetesrequired
    history • used at CONTEXT
    DM substrate amplifies risk + changes phenotype to diabetic nephropathy primary; renal.diabetic-nephropathy.v1 if predominant
  • cardiovascular_disease
    history • used at CONTEXT
    CV disease drives target BP intensification + statin + antiplatelet (AHA 2017)
  • family_history_ckd
    history • used at CONTEXT
    Familial APOL1, PKD, hereditary nephritis differentials (KDIGO 2012 CKD)
  • ancestry_african
    history • used at CONTEXT
    APOL1 high-risk G1/G2 genotype 13% of African-ancestry patients — amplifies HTN-CKD progression
  • current_antihypertensivesrequired
    medication • used at CONTEXT
    Tier ladder review — ACEi/ARB, CCB, thiazide, spironolactone, finerenone, SGLT2i (KDIGO 2024 CKD)
  • renal_ultrasound
    imaging • used at INITIAL_WORKUP
    Symmetric small kidneys = chronic HTN-CKD; asymmetric = RAS; cyst burden = PKD (KDIGO 2012 CKD)

12-phase flow (12)

  1. 1FRAME
    Hypertensive nephrosclerosis = chronic HTN + progressive CKD; KDIGO heat-map stage + APOL1 substrate + RAS exclusion (KDIGO 2012 CKD)
    inputs: creatinine, uacr, sbp
    advance: KDIGO stage + HTN-CKD pivot suspected
  2. 2ENTRY
    Declining eGFR / persistent modest albuminuria / long-standing HTN / malignant phenotype / renovascular suspicion (KDIGO 2012 CKD; AHA 2017)
    inputs: creatinine
    advance: HTN-CKD context confirmed
  3. 3CONTEXT
    Age + sex + ancestry + DM + CV + family hx + current antihypertensives + BP control history (KDIGO 2012 CKD; AHA 2017)
    inputs: age, sex, diabetes, current_antihypertensives
    advance: Context catalogued
  4. 4RED_FLAGS
    Malignant HTN (BP >180/120 + AKI + TMA + retinopathy) → STAT IV BP reduction + plasmapheresis if TMA; flash pulm edema → bilateral RAS suspicion; refractory hyperkalemia (KDIGO 2012 CKD; AHA 2017)
    inputs: sbp, dbp, potassium
    advance: Acute escalation decision made
  5. 5INITIAL_WORKUP
    BMP + UACR + UA + lipid + CBC + iPTH/phos/Ca/Hgb/bicarb if eGFR <60; renal US (KDIGO 2012 CKD; KDIGO CKD-MBD 2017)
    inputs: urinalysis, renal_ultrasound
    actions: panel.renal, panel.cbc, panel.lipid
    advance: Baseline workup back
  6. 6BRANCHING_WORKUP
    APOL1 genotype if African ancestry + atypical; biopsy if active sediment / rapid decline / nephrotic UACR; RAS Doppler / MRA if asymmetric or refractory HTN; FMD angiography if young woman + refractory HTN (KDIGO 2012 CKD; ASTRAL/CORAL)
    advance: Etiology refined
  7. 7DIFFERENTIAL
    Sub-phenotypes: benign_HN_AA_predominant_APOL1 / malignant_HTN_TMA / ischemic_atherosclerotic_RAS / fibromuscular_dysplasia / APOL1_FSGS_overlap / SCD_HTN_CKD / pregnancy_to_chronic / CKD_secondary_HTN / post_radiation_renovascular (KDIGO 2012 CKD)
    advance: Sub-phenotype assigned
  8. 8RISK_STRATIFICATION
    KDIGO heat-map (G × A) + KFRE 4-variable + CV risk; APOL1-positive doubles progression (KDIGO 2012 CKD; SPRINT NEJM 2015)
    inputs: creatinine, uacr, age, sbp
    actions: calc.ckd_epi_2021
    advance: Risk tier documented
  9. 9TREATMENT
    Tier 1 ACEi/ARB + SGLT2i + statin + lifestyle; Tier 2 thiazide / CCB add-on; Tier 3 finerenone if albuminuric + DM overlap; Tier 4 spironolactone if resistant; Tier 5 BP target <120 SPRINT-style for non-DM CKD; Tier 6 renal denervation experimental; malignant HTN → STAT IV labetalol/nicardipine + plasmapheresis if TMA (KDIGO 2012 CKD; SPRINT NEJM 2015; DAPA-CKD; EMPA-KIDNEY)
    inputs: sbp, potassium
    advance: Tier ladder executed
  10. 10DISPOSITION
    Outpatient nephrology primary; admit for malignant HTN / flash pulm edema / AKI-on-CKD / biopsy; ICU for hypertensive emergency with end-organ damage (KDIGO 2012 CKD; AHA 2017)
    advance: Level of care set
  11. 11MONITORING
    eGFR + UACR + BP + K+ q3-6 mo; lipid + CKD-MBD if eGFR <60; eGFR slope quarterly; APOL1+ patients more frequent (KDIGO 2012 CKD)
    inputs: creatinine, uacr, potassium, sbp
    actions: panel.renal
    advance: Monitoring schedule live
  12. 12FOLLOWUP
    q3-6 mo nephrology; transplant + RRT planning at G4 (eGFR <30); cardiology co-management for CV; ophtho for retinopathy; patient education on BP self-monitoring + lifestyle (KDIGO 2012 CKD; AHA 2017)
    advance: Long-term plan documented