Which diagnosis is most likely in a 32-year-old woman with resistant hypertension and high renin?

Which diagnosis is most likely in a 32-year-old woman with resistant hypertension and high renin?

• A. Fibromuscular Dysplasia
• B. Atherosclerotic Renal Artery Stenosis
• C. Renal Cell Carcinoma
• D. Hydronephrosis

Answer: (A)

Renovascular hypertension driven by high renin points to a problem with blood flow to the kidney. In a young woman, the most common cause of this picture is fibromuscular dysplasia, a non-atherosclerotic disease that narrows the renal artery and triggers a strong renin release from the affected kidney. This elevated renin activates the RAAS, producing resistant hypertension despite standard therapy. Fibromuscular dysplasia often presents in women of reproductive age and has a characteristic appearance on angiography—a string-of-beads pattern from alternating areas of narrowing and dilation—though imaging isn’t required to recognize the pattern of physiology. The hypertension tends to improve with targeted treatment such as angioplasty. In contrast, atherosclerotic renal artery stenosis is more typical in older patients with vascular risk factors. Hydronephrosis can cause secondary hypertension but doesn’t usually present with the high-renin, RAAS-driven profile in this age group. Renal cell carcinoma can sometimes cause hypertension but would more often show other signs or symptoms and is less likely in a 32-year-old without such features. Therefore, the most likely diagnosis is fibromuscular dysplasia.

Renovascular hypertension driven by high renin points to a problem with blood flow to the kidney. In a young woman, the most common cause of this picture is fibromuscular dysplasia, a non-atherosclerotic disease that narrows the renal artery and triggers a strong renin release from the affected kidney. This elevated renin activates the RAAS, producing resistant hypertension despite standard therapy. Fibromuscular dysplasia often presents in women of reproductive age and has a characteristic appearance on angiography—a string-of-beads pattern from alternating areas of narrowing and dilation—though imaging isn’t required to recognize the pattern of physiology. The hypertension tends to improve with targeted treatment such as angioplasty.

In contrast, atherosclerotic renal artery stenosis is more typical in older patients with vascular risk factors. Hydronephrosis can cause secondary hypertension but doesn’t usually present with the high-renin, RAAS-driven profile in this age group. Renal cell carcinoma can sometimes cause hypertension but would more often show other signs or symptoms and is less likely in a 32-year-old without such features. Therefore, the most likely diagnosis is fibromuscular dysplasia.