A 55-year old man is referred to the nephrologist by his family doctor because of his persisting hypertension, which has been going on for several years. Despite treatment with a combination of an ACE-inhibitor, a beta-blocker and a calcium channel blocker his blood pressure remains high at 170/105 mm Hg. The patient has smoked for many years and he seems to be suffering from dysbasia. Physical examination reveals a blood pressure of 180/110 mm Hg and a pulse of 68/min. The patient has a body mass index of 31, there’s a soft murmur in the carotid arteries, right > left, and some of the pulsations in the lower extremities are absent. There’s slight pretibial edema. Blood tests reveal: - creatinine: 121 micromol/l - glucose: 7,8 mmol/l - LDL cholesterol: 3,9 mmol/l - ACE-levels: 2 units (very low) Also, the 24h urine sample contains 1,5 g protein and the ECG shows signs of left ventricular hypertrophy. Ultrasound shows a left kidney of 10,2 cm and a the right one is 9,7 cm. The patient is prescribed a diuretic and is asked to return in 6 weeks. Only 4 weeks later, the patient is back again because he’s not feeling well. Then, his blood pressure is 120/70 mm Hg and he has a pulse of 70/min. However, he clearly has orthostatic hypotension and his creatinine has gone up to 567 micromol/l. Furthermore, his bicarbonate is 15 mmol/l and his potassium level is 6,1 mmol/l. The patient is then admitted. Questions. 1. What’s the most likely diagnosis, at the time the patient presented with hypertension? 2. Could the complication of orthostatic hypotension have been foreseen, and ”“ in that view ”“ was it a right decision to prescribe a diuretic?