Attending Rounds Attending Rounds: A Young Patient with a Family History of Hypertension Aldo J. Peixoto Abstract The evaluation of causes of hypertension in young adults with a family history of hypertension needs to be methodical to identify potentially treatable causes. Renal- and renovascular imaging and measurement of plasma aldosterone and plasma renin activity are at the core of this evaluation in most patients. Pertinent aspects of hypertension in autosomal dominant polycystic kidney disease are discussed with a focus on the role of the endothelium in mediating early hypertension and a review of treatment strategies. Finally, the possibility that autosomal dominant polycystic kidney disease and primary aldosteronism are connected beyond coincidence is explored; evidence to support it is scant, although there is a likely role for aldosterone excess and the resultant hypokalemia in promoting cyst growth. Clin J Am Soc Nephrol ▪: ccc–ccc, 2014. doi: 10.2215/CJN.02240314 Case Presentation A 36-year-old white man presented for the evaluation of hypertension, hypokalemia, and biochemical evi- dence of aldosterone excess. His hypertension was first diagnosed at 22 years of age while in the military, and we do not have records of his evaluation at that time. He reported that he had BP levels in the 150/100-mmHg range and that his weight at that time was approximately 180 lb (body mass index [BMI] approximately 24.5 kg/m 2 ). He was treated with lisinopril with prompt and sustained achievement of BP control. He left the military when he was 26 years old, and his new physician performed an evaluation of his hyper- tension. He was asymptomatic. He reported a family history of hypertension starting in early adulthood in his brother, mother, one maternal uncle, and maternal grandfather. He was not aware of any history of strokes, kidney disease, endocrine tumors, or hypokalemia, al- though he had been estranged from his parents since early childhood, and therefore, the information about his family was not complete. His BP was 128/84 mmHg. Other than being over- weight (218 lb; BMI529.4 kg/m 2 ), his examination was unremarkable. Laboratory tests are listed in Table 1. A renal ultrasound showed normal-sized kidneys (right512.2 cm; left512.7 cm), two simple cysts mea- suring 0.9 and 2.1 cm on the left kidney, and one simple cyst measuring 1.4 cm on the right kidney. Doppler examination did not show renal artery stenosis. His physician reassured him about the laboratory results, advised him to exercise and lose weight, and continued treatment with lisinopril as a single-agent therapy. Case Discussion: The General Approach to Young Patients with a Family History of Hypertension The overall prevalence of hypertension among adolescents ages 15–17 years in the United States is approximately 1.5% (higher among obese and lower among leaner adolescents) (1). Population data in young adults show a growing number of patients with hyper- tension among those ages 18–39 years, now in the 7.5% range (2). Despite the growing prevalence of hyperten- sion among young individuals, especially those who are overweight, the overall prevalence is low enough that a critical evaluation of hypertension in such pa- tients with the goal of identifying potentially treatable causes is justified. The prevalence of secondary hy- pertension among adolescents with hypertension was estimated as 65% (3), although a more recent study brings this estimate to ,45% (4). The coexis- tence of obesity, although associated with an increase in the prevalence of hypertension in children and ado- lescents, was not independently associated with the likelihood of a diagnosis of secondary hypertension in the only study that explored it (4). Therefore, the presence of obesity should not deter the clinician from a search for secondary causes. After the diagnosis of hypertension is firmly es- tablished, preferably with confirmation by out-of- office BP measurements, the clinician should rule out the use of hypertensogenic substances, such as glucocorticoids, anabolic steroids, nonsteroidal anti- inflammatory agents, oral contraceptives, sympa- thomimetic amines (including nasal decongestants, psychostimulants used for the treatment of attention deficit disorder, ephedra, cocaine, and amphetamines), selective serotonin and norepinephrine reuptake inhibitors, calcineurin inhibitors, and anti–vascular endothelial growth factor agents. On the basis of the assumption that these initial screens are nega- tive, Figure 1 presents an algorithm that can guide the systematic evaluation of a young adult present- ing with hypertension, regardless of family history. Table 2 complements Figure 1 by providing a list of clues to guide the appropriate investigations that are Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut Correspondence: Dr. Aldo J. Peixoto, Section of Nephrology, Boardman 114, 330 Cedar Street, New Haven, CT 06520. Email aldo.peixoto@ yale.edu www.cjasn.org Vol ▪ ▪▪▪, 2014 Copyright © 2014 by the American Society of Nephrology 1 . Published on August 4, 2014 as doi: 10.2215/CJN.02240314 CJASN ePress