Managing malignant hypertension with renal TMA: a case for caution in blood-pressure reduction

Malignant hypertension with renal thrombotic microangiopathy is a rare yet serious cause of acute kidney injury (AKI). Patients are often treated with antihypertensive therapy; however, managing their blood pressure is complex, with targets for initial treatment unclear. We report on a 55-year-old male with severe hypertension (blood pressure 210/140 mmHg), AKI (serum creatinine 9.27 mg/dL), anemia (hemoglobin 7.6 g/dL), thrombocytopenia (platelets 113 k/μL), and renal biopsy confirming malignant arteriolar nephrosclerosis and thrombotic microangiopathy. Previously prescribed 20-mg azilsartan daily, he lost consciousness the next day and was urgently admitted with a blood pressure of 118 mmHg and increased serum creatinine from 1.28 to 9.27 mg/dL over 6 months. Azilsartan was stopped; blood pressure managed with 12.5 mg of losartan daily, targeting systolic pressure between 150 and 160 mmHg. His creatinine peaked on day 14; however, treatment with 12.5 - 50 mg/day of losartan and 5 - 10 mg/day of amlodipine gradually improved renal function to 4.48 mg/dL by month ten without hemodialysis or further syncope. Our case suggests a gradual approach to blood-pressure management to avoid ischemic risks.