A 55-year-old man presents with blood pressure 220/130 mmHg, serum creatinine rising from 1.2 to 3.1 mg/dL over 48 hours, urinalysis showing haematuria and RBC casts, fundoscopic haemorrhages and papilloedema, and Hb 8.5 g/dL with fragmented red cells. What is the diagnosis and most critical initial treatment?

• A Pre-eclampsia — IV magnesium + hydralazine
• B Hypertensive urgency — oral amlodipine to reduce BP over 24–48 hours
• C TTP/HUS — plasma exchange as primary treatment
• D Accelerated malignant hypertension with MAHA — IV labetalol to reduce BP by 20–25% in first hour ✓

Explanation

Malignant hypertension (accelerated hypertension with papilloedema and target-organ damage) with microangiopathic haemolytic anaemia (MAHA — fragmented RBCs), acute kidney injury (fibrinoid necrosis of renal arterioles), and hypertensive retinopathy represents a hypertensive emergency. Treatment requires immediate IV antihypertensive therapy targeting a 20–25% reduction in MAP in the first hour (not rapid normalisation, to avoid cerebral ischaemia). IV labetalol or nicardipine are preferred agents; nitroprusside is an alternative. Aggressive BP lowering paradoxically worsens renal and cerebral perfusion in chronic hypertension.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.