Renovascular hypertension — ABIM Board MCQ

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ModerateCardiovascularRenovascular hypertensionABIM Board

A 61-year-old woman has abrupt worsening of previously controlled hypertension. One week after lisinopril is started, her serum creatinine increases from 1.0 to 1.7 mg/dL. Examination reveals an abdominal bruit. Kidney ultrasonography shows a right kidney length of 8.6 cm and a left kidney length of 10.2 cm. Urinalysis is bland. Which of the following is the most appropriate initial diagnostic study?

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Correct answer: C — Renal artery duplex ultrasonography

The correct answer is C. Abrupt worsening of hypertension, an abdominal bruit, asymmetric kidney size, bland urine sediment, and a greater than 30% creatinine increase after ACE-inhibitor initiation strongly suggest renovascular hypertension, likely from atherosclerotic renal artery stenosis in this patient. Renal artery duplex ultrasonography is an appropriate initial noninvasive study and evaluates renal arterial flow without iodinated or gadolinium contrast. Metanephrines evaluate pheochromocytoma, which typically causes episodic headache, diaphoresis, and palpitations. The aldosterone-renin ratio screens for primary aldosteronism, often associated with suppressed renin and hypokalemia. Kidney biopsy is inappropriate because there is no proteinuria or active urine sediment suggesting intrinsic renal disease. Urine eosinophils have poor diagnostic performance and would not evaluate renal artery stenosis.

Reference: American Heart Association, When Is Renovascular Hypertension Amenable to Revascularization?, published 2022 and updated July 23, 2026. https://professional.heart.org/en/science-news/revascularization-for-renovascular-disease/Commentary