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renal.hypertensive-nephrosclerosis.v1PRODUCTION
renal.hypertensive-nephrosclerosis.v1

Hypertensive Nephrosclerosis (HTN-CKD)

nephrologychronicacuteadult
Hard-required inputs
0 / 10
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Hypertensive nephrosclerosis = chronic HTN + progressive CKD; KDIGO heat-map stage + APOL1 substrate + RAS exclusion (KDIGO 2012 CKD)

Inputs
3
Actions
0
Advance rule
Set
Advance when

KDIGO stage + HTN-CKD pivot suspected

Patient inputs (14)

Age + ancestry stratify APOL1 + FMD vs atherosclerotic RAS probability

FMD predominantly young women; atherosclerotic RAS older male smokers

eGFR core input — KDIGO staging G1-G5 (KDIGO 2012 CKD)

A1/A2/A3 sub-staging — HTN-CKD typically A1-A2; A3 (>300) suggests overlap with diabetic / glomerular / APOL1-FSGS (KDIGO 2012 CKD)

ACEi/ARB + finerenone + spironolactone tolerability monitoring (KDIGO 2024 CKD)

BP target <120/80 SPRINT-driven for CKD-non-DM; <130/80 for DKD overlap (SPRINT NEJM 2015; KDIGO 2024)

DBP component; malignant HTN if DBP >120

DM substrate amplifies risk + changes phenotype to diabetic nephropathy primary; renal.diabetic-nephropathy.v1 if predominant

Tier ladder review — ACEi/ARB, CCB, thiazide, spironolactone, finerenone, SGLT2i (KDIGO 2024 CKD)

Bland sediment expected in pure HTN-CKD; active sediment → biopsy for GN overlap (KDIGO 2012 CKD)

CV disease drives target BP intensification + statin + antiplatelet (AHA 2017)

Familial APOL1, PKD, hereditary nephritis differentials (KDIGO 2012 CKD)

APOL1 high-risk G1/G2 genotype 13% of African-ancestry patients — amplifies HTN-CKD progression

Symmetric small kidneys = chronic HTN-CKD; asymmetric = RAS; cyst burden = PKD (KDIGO 2012 CKD)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement
  • informationallife_threateningmalignant_HTN_TMA
    BP >180/120 + AKI + MAHA + thrombocytopenia + grade III/IV retinopathy → STAT IV BP reduction + plasmapheresis if TMA (AHA 2017; KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebenign_HN_AA_predominant_APOL1
    African-ancestry adult with HTN-CKD + APOL1 high-risk G1/G2 genotype — 7-10× progression amplification
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereischemic_atherosclerotic_RAS
    Asymmetric kidneys + refractory HTN + flash pulm edema + atherosclerotic burden — atherosclerotic RAS (ASTRAL; CORAL)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefibromuscular_dysplasia
    Young woman + refractory HTN + asymmetric kidneys / string-of-beads on angio — FMD (Olin-Sealove Mayo Clin 2010)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereAPOL1_FSGS_overlap
    African-ancestry + nephrotic-range UACR + APOL1+ — collapsing FSGS variant overlap (KDIGO GN 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereSCD_HTN_CKD
    Sickle cell disease + HTN + progressive CKD — sickle nephropathy overlay (KDIGO 2012 CKD; ASH 2014)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepregnancy_to_chronic
    Pregnancy-induced HTN (preeclampsia, eclampsia, HELLP) → chronic HTN-CKD postpartum (ACOG 2020; KDIGO 2012 CKD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateCKD_secondary_HTN
    CKD causes secondary HTN — volume + RAS activation + sympathetic; bidirectional (KDIGO 2012 CKD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepost_radiation_renovascular
    Post-radiation renovascular HTN — flank radiation history + new HTN + asymmetric kidneys (Cassady IJROBP 1995)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

Hypertensive nephrosclerosis — BP control + renoprotection tier ladder + malignant HTN STAT pathway (KDIGO 2012 CKD; SPRINT NEJM 2015; DAPA-CKD; EMPA-KIDNEY)
axis: hypertensive_nephrosclerosis_bp_renoprotection_ladderstep 1 - Step 1 — RAS blockade foundational
Selected step "Step 1 — RAS blockade foundational" — eGFR >20 + K+ <5.0 + no bilateral RAS (KDIGO 2024 CKD)
  • lisinopril
    first line
    ACEi
    10 mg PO daily; titrate to max 40 mg • PO • daily
    triggers: htn_ckd_egfr_gt_20, no_history_aceiarb_intolerance
    KDIGO 2012 CKD — RAS blockade slows progression; titrate to max-tolerated dose; recheck Cr+K at 1-2 wk
    rxcui 29046
  • losartan
    first line
    ARB
    50 mg PO daily; titrate to 100 mg • PO • daily
    triggers: acei_intolerant_cough_angioedema
    KDIGO 2012 CKD — ARB if ACEi intolerant; same renoprotective effect
    rxcui 52175

outpatient playbook — drug actions (7)

  1. 1. lisinopril titration
    Start 10 mg, titrate to max 40 mg • PO • daily
    trigger: HTN-CKD foundational
    KDIGO 2012 CKD
  2. 2. dapagliflozin add
    10 mg PO daily • PO • daily
    trigger: eGFR ≥20 + progressive
    DAPA-CKD
  3. 3. chlorthalidone add
    12.5-25 mg PO daily • PO • daily
    trigger: BP unmet on RAS+SGLT2i
    AHA 2017
  4. 4. amlodipine add
    5-10 mg PO daily • PO • daily
    trigger: BP unmet on 3-drug
    AHA 2017
  5. 5. spironolactone if resistant
    12.5-25 mg PO daily • PO • daily
    trigger: Resistant HTN + K+ <5
    PATHWAY-2; route cardio.htn.resistant.v1
  6. 6. finerenone if DM albuminuric
    10-20 mg PO daily • PO • daily
    trigger: DM + UACR ≥30 + K+ <5
    FIDELIO-DKD
  7. 7. atorvastatin
    40-80 mg PO daily • PO • daily
    trigger: ASCVD risk + CKD
    AHA 2018 + KDIGO lipid 2014

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Declining eGFR in long-standing HTN patient ± modest albuminuria (KDIGO 2012 CKD); Persistent UACR 30-300 + chronic HTN (no diabetes) — hypertensive CKD phenotype (KDIGO 2012 CKD); Long-standing uncontrolled HTN ≥10 yrs (KDIGO 2012 CKD; AHA 2017).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Hypertensive Nephrosclerosis (HTN-CKD)** (renal.hypertensive-nephrosclerosis.v1).
Phenotype framing: 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)
Scope: Hypertensive nephrosclerosis = chronic HTN + progressive CKD; KDIGO heat-map stage + APOL1 substrate + RAS exclusion (KDIGO 2012 CKD)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Hypertensive nephrosclerosis — BP control + renoprotection tier ladder + malignant HTN STAT pathway (KDIGO 2012 CKD; SPRINT NEJM 2015; DAPA-CKD; EMPA-KIDNEY)** — step "Step 1 — RAS blockade foundational".
1. lisinopril 10 mg PO daily; titrate to max 40 mg PO daily (ACEi, first line) — KDIGO 2012 CKD — RAS blockade slows progression; titrate to max-tolerated dose; recheck Cr+K at 1-2 wk
2. losartan 50 mg PO daily; titrate to 100 mg PO daily (ARB, first line) — KDIGO 2012 CKD — ARB if ACEi intolerant; same renoprotective effect

Setting playbook (outpatient) — Tier-ladder BP + renoprotection + APOL1 / RAS / FMD differentiation + CV risk reduction (KDIGO 2012 CKD; AHA 2017; SPRINT NEJM 2015)
3. lisinopril titration Start 10 mg, titrate to max 40 mg PO daily — HTN-CKD foundational (KDIGO 2012 CKD)
4. dapagliflozin add 10 mg PO daily PO daily — eGFR ≥20 + progressive (DAPA-CKD)
5. chlorthalidone add 12.5-25 mg PO daily PO daily — BP unmet on RAS+SGLT2i (AHA 2017)
6. amlodipine add 5-10 mg PO daily PO daily — BP unmet on 3-drug (AHA 2017)
7. spironolactone if resistant 12.5-25 mg PO daily PO daily — Resistant HTN + K+ <5 (PATHWAY-2; route cardio.htn.resistant.v1)
8. finerenone if DM albuminuric 10-20 mg PO daily PO daily — DM + UACR ≥30 + K+ <5 (FIDELIO-DKD)
9. atorvastatin 40-80 mg PO daily PO daily — ASCVD risk + CKD (AHA 2018 + KDIGO lipid 2014)

Non-pharmacologic actions:
- DASH diet + sodium <2 g/day (AHA 2017)
- BP target <120/80 SPRINT-style for non-DM CKD (SPRINT NEJM 2015)
- BP target <130/80 for DM-CKD overlap (KDIGO 2024)
- Weight loss + exercise (AHA 2017)
- Smoking cessation (AHA 2017)
- Annual ophthalmology for HTN retinopathy + DM if applicable

AVOID / contraindication checks:
- No_combined_acei_arb_ras_blockade (KDIGO 2012 CKD; ONTARGET)
- Hold_ras_blockade_during_severe_AKI (KDIGO 2012 AKI)
- Avoid_NSAIDs_in_HTN_CKD (KDIGO 2012 CKD)
- MAP_reduction_no_more_than_25_percent_first_hour_malignant_HTN (AHA 2017)
- RAS_stent_NOT_routine_per_ASTRAL_CORAL (ASTRAL 2009; CORAL 2014)
- Balloon_angioplasty_NOT_stent_for_FMD
- Monitor_K_within_1_2_wk_after_RAS_or_MRA_initiation (KDIGO 2024)

Monitoring

Regimen monitoring:
- Cr K at 1 2 wk post RAS initiation (KDIGO 2024)
- BP self monitoring logs at each visit (AHA 2017)
- eGFR UACR q3 6 mo (KDIGO 2012 CKD)
- K at 1 4 wk after finerenone or spironolactone (FIDELIO-DKD)
- MAP continuous during malignant HTN titration (AHA 2017)

Setting (outpatient) monitoring:
- BP at every visit + home log (AHA 2017)
- eGFR + UACR q3-6 mo (KDIGO 2012 CKD)
- K+ at 1-2 wk after each RAS / MRA change (KDIGO 2024)
- CKD-MBD labs if eGFR <60 (KDIGO CKD-MBD 2017)

Follow-up plan: 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)
- Close-out criterion: Long-term plan documented

Monitoring phase: eGFR + UACR + BP + K+ q3-6 mo; lipid + CKD-MBD if eGFR <60; eGFR slope quarterly; APOL1+ patients more frequent (KDIGO 2012 CKD)

Disposition

Current setting: outpatient — Tier-ladder BP + renoprotection + APOL1 / RAS / FMD differentiation + CV risk reduction (KDIGO 2012 CKD; AHA 2017; SPRINT NEJM 2015)

Disposition criteria:
- Continue nephrology q3-6 mo if eGFR <60 (KDIGO 2012 CKD)
- Refer cardiology if refractory HTN or CV disease (AHA 2017)

Escalation triggers (move to higher acuity):
- Sustained BP >150/95 despite max tier → resistant HTN workup → cardio.htn.resistant.v1
- Rapid eGFR decline (>5 ml/min/year) → biopsy consideration (KDIGO 2012 CKD)
- New nephrotic UACR → renal.fsgs.v1 or biopsy for APOL1-FSGS overlap

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] BP >180/120 + AKI + MAHA + thrombocytopenia + grade III/IV retinopathy → STAT IV BP reduction + plasmapheresis if TMA (AHA 2017; KDIGO 2012 AKI)
- [SEVERE] African-ancestry adult with HTN-CKD + APOL1 high-risk G1/G2 genotype — 7-10× progression amplification
- [SEVERE] Asymmetric kidneys + refractory HTN + flash pulm edema + atherosclerotic burden — atherosclerotic RAS (ASTRAL; CORAL)

Citations

- KDIGO 2021 BP in CKD + KDIGO 2024 CKD + AASK (JAMA 2002) + SPRINT (NEJM 2015) + SGLT2i renal protection (EMPA-KIDNEY 2023) [PMID:12435255](https://pubmed.ncbi.nlm.nih.gov/12435255/)
- Cited evidence (PMID 26551272) [PMID:26551272](https://pubmed.ncbi.nlm.nih.gov/26551272/)
- Cited evidence (PMID 33637192) [PMID:33637192](https://pubmed.ncbi.nlm.nih.gov/33637192/)
- Cited evidence (PMID 38490803) [PMID:38490803](https://pubmed.ncbi.nlm.nih.gov/38490803/)
- Cited evidence (PMID 36331190) [PMID:36331190](https://pubmed.ncbi.nlm.nih.gov/36331190/)

Last reconciled with current guidelines: 2026-05-22.
References
  • KDIGO 2021 BP in CKD + KDIGO 2024 CKD + AASK (JAMA 2002) + SPRINT (NEJM 2015) + SGLT2i renal protection (EMPA-KIDNEY 2023) — PMID:12435255
  • Cited evidence (PMID 26551272) — PMID:26551272
  • Cited evidence (PMID 33637192) — PMID:33637192
  • Cited evidence (PMID 38490803) — PMID:38490803
  • Cited evidence (PMID 36331190) — PMID:36331190