{"version":"1.0.0","segments":[{"startTime":0.375,"endTime":3.3,"body":"[upbeat intro music]"},{"startTime":3.3,"endTime":5.7,"body":"[Dr. Handy] Hi, welcome"},{"startTime":3.3,"endTime":5.7,"body":"to Harrison's PodClass,"},{"startTime":5.7,"endTime":8.73,"body":"where we discuss important"},{"startTime":5.7,"endTime":8.73,"body":"concepts in internal medicine."},{"startTime":8.73,"endTime":9.96,"body":"I'm Cathy Handy."},{"startTime":9.96,"endTime":11.728,"body":"[Dr. Wiener] And I'm Charlie"},{"startTime":9.96,"endTime":11.728,"body":"Wiener, and we're coming to you"},{"startTime":11.728,"endTime":13.84,"body":"from the Johns Hopkins School of Medicine."},{"startTime":15.9,"endTime":17.459,"body":"Welcome to episode 89,"},{"startTime":17.459,"endTime":20.5,"body":"a 66-year-old woman with"},{"startTime":17.459,"endTime":20.5,"body":"elevated blood pressure."},{"startTime":20.5,"endTime":22.0,"body":"- Hey, Cathy."},{"startTime":20.5,"endTime":22.0,"body":"- [Dr. Handy] Hey, Charlie."},{"startTime":22.0,"endTime":25.02,"body":"[Dr. Wiener] So, today's"},{"startTime":22.0,"endTime":25.02,"body":"patient is a 66-year-old woman"},{"startTime":25.02,"endTime":26.38,"body":"who presents to the emergency room"},{"startTime":26.38,"endTime":29.3,"body":"with malaise, confusion, and a headache."},{"startTime":29.3,"endTime":33.202,"body":"At triage, her blood pressure"},{"startTime":29.3,"endTime":33.202,"body":"is found to be 220/105."},{"startTime":33.202,"endTime":34.143,"body":"[Dr. Handy] Stop right there."},{"startTime":34.143,"endTime":35.96,"body":"So, the combination right off the bat"},{"startTime":35.96,"endTime":38.81,"body":"of a very high blood pressure"},{"startTime":35.96,"endTime":38.81,"body":"and neurologic findings"},{"startTime":38.81,"endTime":41.66,"body":"is already consistent with"},{"startTime":38.81,"endTime":41.66,"body":"hypertensive emergency."},{"startTime":41.66,"endTime":43.25,"body":"You should already be"},{"startTime":41.66,"endTime":43.25,"body":"thinking about treatment"},{"startTime":43.25,"endTime":45.46,"body":"and of course a complete physical exam."},{"startTime":45.46,"endTime":47.21,"body":"[Dr. Wiener] Right, so you're"},{"startTime":45.46,"endTime":47.21,"body":"saying that the difference"},{"startTime":47.21,"endTime":49.36,"body":"between hypertensive urgency and emergency"},{"startTime":49.36,"endTime":51.89,"body":"is the presence of end"},{"startTime":49.36,"endTime":51.89,"body":"organ damage in emergency?"},{"startTime":51.89,"endTime":52.723,"body":"[Dr. Handy] Yes."},{"startTime":52.723,"endTime":54.56,"body":"[Dr. Wiener] So I assume that"},{"startTime":52.723,"endTime":54.56,"body":"can be neurologic changes,"},{"startTime":54.56,"endTime":55.75,"body":"as in this patient,"},{"startTime":55.75,"endTime":58.92,"body":"or also chest pain, new"},{"startTime":55.75,"endTime":58.92,"body":"hematuria, proteinuria,"},{"startTime":58.92,"endTime":61.07,"body":"or other signs of vascular insufficiency?"},{"startTime":61.07,"endTime":63.44,"body":"[Dr. Handy] Yeah, and some"},{"startTime":61.07,"endTime":63.44,"body":"require a systolic blood pressure"},{"startTime":63.44,"endTime":67.73,"body":"of over 180 or a diastolic"},{"startTime":63.44,"endTime":67.73,"body":"blood pressure over 110,"},{"startTime":67.73,"endTime":69.988,"body":"but the point is that it's"},{"startTime":67.73,"endTime":69.988,"body":"an uncontrolled elevated"},{"startTime":69.988,"endTime":72.04,"body":"blood pressure with end organ damage,"},{"startTime":72.04,"endTime":74.872,"body":"and if it's not treated,"},{"startTime":72.04,"endTime":74.872,"body":"it may become irreversible."},{"startTime":74.872,"endTime":76.92,"body":"So, let's go back to the patient."},{"startTime":76.92,"endTime":78.965,"body":"[Dr. Wiener] Okay, so on"},{"startTime":76.92,"endTime":78.965,"body":"physical exam, she has"},{"startTime":78.965,"endTime":82.47,"body":"no neurologic asymmetry but"},{"startTime":78.965,"endTime":82.47,"body":"she's definitely somnolent"},{"startTime":82.47,"endTime":85.07,"body":"and only oriented to person and city."},{"startTime":85.07,"endTime":87.084,"body":"Her family says this is"},{"startTime":85.07,"endTime":87.084,"body":"radically different from her"},{"startTime":87.084,"endTime":90.37,"body":"baseline and it's been going"},{"startTime":87.084,"endTime":90.37,"body":"on for about one to two days."},{"startTime":90.37,"endTime":91.51,"body":"Her lungs are clear"},{"startTime":91.51,"endTime":95.31,"body":"and her cardiac examination"},{"startTime":91.51,"endTime":95.31,"body":"is only notable for a loud S4."},{"startTime":95.31,"endTime":97.5,"body":"Additional physical"},{"startTime":95.31,"endTime":97.5,"body":"findings that you notice"},{"startTime":97.5,"endTime":100.38,"body":"are skin thickening of her arms and legs,"},{"startTime":100.38,"endTime":103.96,"body":"facial telangiectasias, and"},{"startTime":100.38,"endTime":103.96,"body":"a decreased oral aperture."},{"startTime":103.96,"endTime":105.7,"body":"[Dr. Handy] Well, the physical"},{"startTime":103.96,"endTime":105.7,"body":"exam findings that you"},{"startTime":105.7,"endTime":108.557,"body":"mentioned of the skin thickening,"},{"startTime":105.7,"endTime":108.557,"body":"the facial telangiectasias"},{"startTime":108.557,"endTime":110.25,"body":"and the decreased oral aperture"},{"startTime":110.25,"endTime":112.48,"body":"are characteristic of scleroderma."},{"startTime":112.48,"endTime":115.06,"body":"Can you tell me more about her"},{"startTime":112.48,"endTime":115.06,"body":"initial laboratory studies,"},{"startTime":115.06,"endTime":117.17,"body":"as there can be organ involvement as well,"},{"startTime":117.17,"endTime":119.728,"body":"which may be contributing"},{"startTime":117.17,"endTime":119.728,"body":"to her current presentation?"},{"startTime":119.728,"endTime":122.96,"body":"[Dr. Wiener] Well, she has"},{"startTime":119.728,"endTime":122.96,"body":"a creatinine of 3.5 mg/dL,"},{"startTime":122.96,"endTime":125.52,"body":"a hemoglobin of 7 g/dL,"},{"startTime":125.52,"endTime":127.67,"body":"platelets are 75,000,"},{"startTime":127.67,"endTime":130.18,"body":"LDH is elevated at 700,"},{"startTime":130.18,"endTime":132.06,"body":"and these are all different"},{"startTime":130.18,"endTime":132.06,"body":"from her baseline,"},{"startTime":132.06,"endTime":133.47,"body":"which was previously normal."},{"startTime":133.47,"endTime":135.347,"body":"[Dr. Handy] Okay, so those"},{"startTime":133.47,"endTime":135.347,"body":"labs that you just mentioned,"},{"startTime":135.347,"endTime":137.453,"body":"it sounds like she has"},{"startTime":135.347,"endTime":137.453,"body":"acute kidney injury,"},{"startTime":137.453,"endTime":141.41,"body":"anemia, thrombocytopenia,"},{"startTime":137.453,"endTime":141.41,"body":"and a very elevated LDH."},{"startTime":141.41,"endTime":142.79,"body":"What does the question ask?"},{"startTime":142.79,"endTime":143.9,"body":"[Dr. Wiener] So the question asks,"},{"startTime":143.9,"endTime":145.577,"body":"what is the appropriate initial treatment"},{"startTime":145.577,"endTime":147.42,"body":"for her current presentation?"},{"startTime":147.42,"endTime":150.15,"body":"And the options are, amlodipine;"},{"startTime":150.15,"endTime":152.288,"body":"option B. is captopril;"},{"startTime":152.288,"endTime":154.84,"body":"option C. is eculizumab;"},{"startTime":154.84,"endTime":156.85,"body":"option D. is heparin;"},{"startTime":156.85,"endTime":159.12,"body":"and option E. is plasmapheresis."},{"startTime":159.12,"endTime":160.807,"body":"[Dr. Handy] Well, the key"},{"startTime":159.12,"endTime":160.807,"body":"to the answer in this case"},{"startTime":160.807,"endTime":164.423,"body":"is to recognize that this"},{"startTime":160.807,"endTime":164.423,"body":"is scleroderma renal crisis."},{"startTime":164.423,"endTime":165.51,"body":"[Dr. Wiener] Tell me more about that."},{"startTime":165.51,"endTime":166.99,"body":"[Dr. Handy] Scleroderma renal crisis"},{"startTime":166.99,"endTime":169.49,"body":"may occur in 10% to 15% of patients"},{"startTime":169.49,"endTime":171.37,"body":"with diffuse systemic sclerosis,"},{"startTime":171.37,"endTime":174.23,"body":"but it's much less common"},{"startTime":171.37,"endTime":174.23,"body":"in only about 2% of those"},{"startTime":174.23,"endTime":176.57,"body":"who have limited systemic sclerosis."},{"startTime":176.57,"endTime":178.8,"body":"The physical description that you gave,"},{"startTime":178.8,"endTime":181.76,"body":"with the diffuse skin"},{"startTime":178.8,"endTime":181.76,"body":"changes, telangiectasias,"},{"startTime":181.76,"endTime":183.25,"body":"and limited oral orifice"},{"startTime":183.25,"endTime":186.3,"body":"are all consistent with"},{"startTime":183.25,"endTime":186.3,"body":"diffuse systemic scleroderma."},{"startTime":186.3,"endTime":189.85,"body":"[Dr. Wiener] Okay, let's discuss"},{"startTime":186.3,"endTime":189.85,"body":"scleroderma renal crisis specifically."},{"startTime":189.85,"endTime":191.75,"body":"[Dr. Handy] Well, it's the"},{"startTime":189.85,"endTime":191.75,"body":"most severe manifestation"},{"startTime":191.75,"endTime":193.972,"body":"of renal involvement and"},{"startTime":191.75,"endTime":193.972,"body":"it typically presents"},{"startTime":193.972,"endTime":196.518,"body":"within the first four years of diagnosis."},{"startTime":196.518,"endTime":199.348,"body":"It's characterized by"},{"startTime":196.518,"endTime":199.348,"body":"accelerated hypertension,"},{"startTime":199.348,"endTime":201.475,"body":"a rapid decline in renal function,"},{"startTime":201.475,"endTime":204.552,"body":"nephrotic range"},{"startTime":201.475,"endTime":204.552,"body":"proteinuria, and hematuria."},{"startTime":204.552,"endTime":206.465,"body":"Retinopathy and encephalopathy"},{"startTime":206.465,"endTime":208.49,"body":"may accompany the hypertension."},{"startTime":208.49,"endTime":211.392,"body":"Salt and water retention"},{"startTime":208.49,"endTime":211.392,"body":"with microvascular injury"},{"startTime":211.392,"endTime":213.45,"body":"can lead to pulmonary edema."},{"startTime":213.45,"endTime":215.18,"body":"And cardiac manifestations,"},{"startTime":215.18,"endTime":217.94,"body":"like myocarditis,"},{"startTime":215.18,"endTime":217.94,"body":"pericarditis, and arrhythmias,"},{"startTime":217.94,"endTime":220.54,"body":"denote an especially poor prognosis."},{"startTime":220.54,"endTime":223.08,"body":"In very severe cases,"},{"startTime":220.54,"endTime":223.08,"body":"the patient may develop"},{"startTime":223.08,"endTime":226.35,"body":"posterior reversal"},{"startTime":223.08,"endTime":226.35,"body":"encephalopathy, or PRES,"},{"startTime":226.35,"endTime":228.725,"body":"which, frankly, I'm concerned"},{"startTime":226.35,"endTime":228.725,"body":"about in this patient."},{"startTime":228.725,"endTime":230.367,"body":"[Dr. Wiener] This patient"},{"startTime":228.725,"endTime":230.367,"body":"seems to have had a fall"},{"startTime":230.367,"endTime":231.825,"body":"in her hemoglobin and her platelets,"},{"startTime":231.825,"endTime":233.732,"body":"and she has an elevated LDH."},{"startTime":233.732,"endTime":235.57,"body":"Is that part of the crisis also?"},{"startTime":235.57,"endTime":237.08,"body":"[Dr. Handy] Yeah. Sorry for"},{"startTime":235.57,"endTime":237.08,"body":"not mentioning that before."},{"startTime":237.08,"endTime":240.09,"body":"So microangiopathic"},{"startTime":237.08,"endTime":240.09,"body":"hemolytic anemia, or MAHA,"},{"startTime":240.09,"endTime":242.323,"body":"is presented in more"},{"startTime":240.09,"endTime":242.323,"body":"than half of patients,"},{"startTime":242.323,"endTime":244.84,"body":"however, true coagulopathy is rare."},{"startTime":244.84,"endTime":247.197,"body":"[Dr. Wiener] What's the"},{"startTime":244.84,"endTime":247.197,"body":"pathology of this disorder?"},{"startTime":247.197,"endTime":249.165,"body":"[Dr. Handy] On renal"},{"startTime":247.197,"endTime":249.165,"body":"biopsy during a crisis,"},{"startTime":249.165,"endTime":251.355,"body":"you'll find arcuate artery intima"},{"startTime":251.355,"endTime":254.16,"body":"and medial proliferation"},{"startTime":251.355,"endTime":254.16,"body":"with luminal narrowing."},{"startTime":254.16,"endTime":256.74,"body":"This lesion is described as onion skinning"},{"startTime":256.74,"endTime":259.42,"body":"and it can be accompanied"},{"startTime":256.74,"endTime":259.42,"body":"by glomerular collapse"},{"startTime":259.42,"endTime":261.142,"body":"due to reduced blood flow."},{"startTime":261.142,"endTime":263.45,"body":"Histologically, scleroderma renal crisis"},{"startTime":263.45,"endTime":265.96,"body":"is indistinguishable from"},{"startTime":263.45,"endTime":265.96,"body":"malignant hypertension,"},{"startTime":265.96,"endTime":267.693,"body":"with which it can coexist."},{"startTime":267.693,"endTime":271.26,"body":"And fibrinoid necrosis and"},{"startTime":267.693,"endTime":271.26,"body":"thrombosis are also common."},{"startTime":271.26,"endTime":273.053,"body":"[Dr. Wiener] Okay, so in"},{"startTime":271.26,"endTime":273.053,"body":"this case, you did go back to"},{"startTime":273.053,"endTime":275.355,"body":"the family, and the family"},{"startTime":273.053,"endTime":275.355,"body":"did confirm that the patient"},{"startTime":275.355,"endTime":278.66,"body":"had a diagnosis of scleroderma"},{"startTime":275.355,"endTime":278.66,"body":"made about two years ago."},{"startTime":278.66,"endTime":281.04,"body":"And the question's specifically"},{"startTime":278.66,"endTime":281.04,"body":"asking about treatment."},{"startTime":281.04,"endTime":283.4,"body":"Which of the medications is the answer?"},{"startTime":283.4,"endTime":285.388,"body":"[Dr. Handy] Yeah. So the"},{"startTime":283.4,"endTime":285.388,"body":"answer is B. captopril."},{"startTime":285.388,"endTime":286.887,"body":"Now, before the availability"},{"startTime":286.887,"endTime":289.865,"body":"of angiotensin-converting"},{"startTime":286.887,"endTime":289.865,"body":"enzyme, or ACE inhibitors,"},{"startTime":289.865,"endTime":292.528,"body":"the mortality rate for"},{"startTime":289.865,"endTime":292.528,"body":"scleroderma renal crisis"},{"startTime":292.528,"endTime":295.17,"body":"was over 90% at one month."},{"startTime":295.17,"endTime":298.635,"body":"Introduction of"},{"startTime":295.17,"endTime":298.635,"body":"renin-angiotensin system blockade"},{"startTime":298.635,"endTime":302.172,"body":"has lowered the mortality"},{"startTime":298.635,"endTime":302.172,"body":"rate to 30% at three years."},{"startTime":302.172,"endTime":305.05,"body":"Nearly two thirds of patients"},{"startTime":302.172,"endTime":305.05,"body":"with scleroderma renal crisis"},{"startTime":305.05,"endTime":306.963,"body":"may require dialysis support,"},{"startTime":306.963,"endTime":308.528,"body":"but recovery of renal function"},{"startTime":308.528,"endTime":310.9,"body":"does happen in about 50% of people,"},{"startTime":310.9,"endTime":314.0,"body":"and the median time that"},{"startTime":310.9,"endTime":314.0,"body":"that takes is about a year."},{"startTime":314.0,"endTime":315.378,"body":"Treatment with ACE inhibition"},{"startTime":315.378,"endTime":317.868,"body":"is the first-line therapy"},{"startTime":315.378,"endTime":317.868,"body":"unless contraindicated,"},{"startTime":317.868,"endTime":320.408,"body":"and the goal of therapy"},{"startTime":317.868,"endTime":320.408,"body":"is to reduce systolic"},{"startTime":320.408,"endTime":323.95,"body":"and diastolic blood pressure by 20 mmHg"},{"startTime":323.95,"endTime":326.12,"body":"and 10 mmHg, respectively."},{"startTime":326.12,"endTime":327.888,"body":"And you want to do that every 24 hours"},{"startTime":327.888,"endTime":329.86,"body":"until the blood pressure is normal."},{"startTime":329.86,"endTime":331.36,"body":"[Dr. Wiener] I assume you chose captopril"},{"startTime":331.36,"endTime":332.86,"body":"because it is the most short-acting"},{"startTime":332.86,"endTime":334.71,"body":"and the easiest to up-titrate."},{"startTime":334.71,"endTime":337.617,"body":"What about angiotensin"},{"startTime":334.71,"endTime":337.617,"body":"II receptor antagonists?"},{"startTime":337.617,"endTime":340.11,"body":"[Dr. Handy] Yes, so initially"},{"startTime":337.617,"endTime":340.11,"body":"captopril is easiest to manage"},{"startTime":340.11,"endTime":343.49,"body":"in these patients who can have"},{"startTime":340.11,"endTime":343.49,"body":"very volatile blood pressures"},{"startTime":343.49,"endTime":345.85,"body":"but both ACE inhibitors and ARBs,"},{"startTime":345.85,"endTime":348.788,"body":"or angiotensin II receptor"},{"startTime":345.85,"endTime":348.788,"body":"antagonists, are effective,"},{"startTime":348.788,"endTime":349.805,"body":"although data suggests"},{"startTime":349.805,"endTime":352.335,"body":"that treatment with ACE"},{"startTime":349.805,"endTime":352.335,"body":"inhibitors is superior."},{"startTime":352.335,"endTime":353.534,"body":"Now, ACE inhibition alone"},{"startTime":353.534,"endTime":355.72,"body":"does not prevent scleroderma renal crisis"},{"startTime":355.72,"endTime":358.5,"body":"but it does reduce the"},{"startTime":355.72,"endTime":358.5,"body":"impact of the hypertension."},{"startTime":358.5,"endTime":359.9,"body":"[Dr. Wiener] Why target that pathway"},{"startTime":359.9,"endTime":362.01,"body":"and not use one of the"},{"startTime":359.9,"endTime":362.01,"body":"other drugs like amlodipine,"},{"startTime":362.01,"endTime":364.67,"body":"which is mentioned in this case"},{"startTime":362.01,"endTime":364.67,"body":"to manage the blood pressure?"},{"startTime":364.67,"endTime":365.58,"body":"[Dr. Handy] Like I mentioned before,"},{"startTime":365.58,"endTime":368.486,"body":"the pathogenesis involves"},{"startTime":365.58,"endTime":368.486,"body":"obliterative vasculopathy"},{"startTime":368.486,"endTime":369.54,"body":"and luminal narrowing"},{"startTime":369.54,"endTime":372.76,"body":"of the renal arcuate"},{"startTime":369.54,"endTime":372.76,"body":"and interlobar arteries."},{"startTime":372.76,"endTime":375.045,"body":"So that's consistent with"},{"startTime":372.76,"endTime":375.045,"body":"intravascular hemolysis,"},{"startTime":375.045,"endTime":377.285,"body":"along with evidence of activation"},{"startTime":377.285,"endTime":379.08,"body":"of the complement pathways."},{"startTime":379.08,"endTime":381.355,"body":"Now, progressive reduction"},{"startTime":379.08,"endTime":381.355,"body":"in renal blood flow"},{"startTime":381.355,"endTime":383.053,"body":"aggravated by vasospasm,"},{"startTime":383.053,"endTime":385.76,"body":"also leads to juxtaglomerular"},{"startTime":383.053,"endTime":385.76,"body":"renin secretion"},{"startTime":385.76,"endTime":388.667,"body":"and activation of angiotensin II."},{"startTime":388.667,"endTime":390.938,"body":"That results in further"},{"startTime":388.667,"endTime":390.938,"body":"renal vasoconstriction,"},{"startTime":390.938,"endTime":392.412,"body":"resulting in a vicious cycle"},{"startTime":392.412,"endTime":394.847,"body":"that culminates in the"},{"startTime":392.412,"endTime":394.847,"body":"accelerated hypertension."},{"startTime":394.847,"endTime":398.028,"body":"So, the ACE inhibition"},{"startTime":394.847,"endTime":398.028,"body":"really works directly"},{"startTime":398.028,"endTime":400.783,"body":"on the pathophysiology of the disease."},{"startTime":400.783,"endTime":403.01,"body":"[Dr. Wiener] Can you use additional"},{"startTime":400.783,"endTime":403.01,"body":"anti-hypertensive agents?"},{"startTime":403.01,"endTime":405.12,"body":"The question mentioned amlodipine."},{"startTime":405.12,"endTime":407.31,"body":"[Dr. Handy] Yes, additional"},{"startTime":405.12,"endTime":407.31,"body":"anti-hypertensive therapy,"},{"startTime":407.31,"endTime":409.03,"body":"such as calcium-channel blockers,"},{"startTime":409.03,"endTime":411.51,"body":"like amlodipine or"},{"startTime":409.03,"endTime":411.51,"body":"nicardipine, may be given"},{"startTime":411.51,"endTime":414.662,"body":"once the dose of drug for"},{"startTime":411.51,"endTime":414.662,"body":"ACE inhibition is maximized."},{"startTime":414.662,"endTime":416.01,"body":"The things to mention, though,"},{"startTime":416.01,"endTime":419.0,"body":"potentially nephrotoxic drugs"},{"startTime":416.01,"endTime":419.0,"body":"should definitely be avoided,"},{"startTime":419.0,"endTime":421.36,"body":"and in patients with"},{"startTime":419.0,"endTime":421.36,"body":"persistent hypertension,"},{"startTime":421.36,"endTime":425.26,"body":"you can add on ARBs or other"},{"startTime":421.36,"endTime":425.26,"body":"calcium channel blockers."},{"startTime":425.26,"endTime":426.892,"body":"[Dr. Wiener] Okay, how about"},{"startTime":425.26,"endTime":426.892,"body":"you run through the other"},{"startTime":426.892,"endTime":429.98,"body":"options quickly just to"},{"startTime":426.892,"endTime":429.98,"body":"finish off the discussion?"},{"startTime":429.98,"endTime":432.53,"body":"[Dr. Handy] Yeah, so eculizumab"},{"startTime":429.98,"endTime":432.53,"body":"is a monoclonal antibody"},{"startTime":432.53,"endTime":435.59,"body":"that binds a terminal"},{"startTime":432.53,"endTime":435.59,"body":"component of complement 5."},{"startTime":435.59,"endTime":438.39,"body":"It's used in atypical"},{"startTime":435.59,"endTime":438.39,"body":"hemolytic uremic syndrome"},{"startTime":438.39,"endTime":440.93,"body":"and paroxysmal nocturnal hematuria,"},{"startTime":440.93,"endTime":443.018,"body":"but that's not what's"},{"startTime":440.93,"endTime":443.018,"body":"happening to this patient."},{"startTime":443.018,"endTime":445.21,"body":"And there's also no role"},{"startTime":443.018,"endTime":445.21,"body":"for heparin to treat"},{"startTime":445.21,"endTime":446.88,"body":"scleroderma renal crisis."},{"startTime":446.88,"endTime":449.16,"body":"[Dr. Wiener] Great, so the"},{"startTime":446.88,"endTime":449.16,"body":"teaching points of this case"},{"startTime":449.16,"endTime":451.35,"body":"are that in a patient with scleroderma,"},{"startTime":451.35,"endTime":453.873,"body":"renal crisis will often present"},{"startTime":451.35,"endTime":453.873,"body":"with findings consistent"},{"startTime":453.873,"endTime":456.32,"body":"with hypertensive emergency, or PRES."},{"startTime":456.32,"endTime":457.75,"body":"It is vital to treat early"},{"startTime":457.75,"endTime":460.64,"body":"by interfering with the"},{"startTime":457.75,"endTime":460.64,"body":"renin-angiotensin axis,"},{"startTime":460.64,"endTime":462.494,"body":"preferably with an ACE inhibitor."},{"startTime":462.494,"endTime":464.636,"body":"[Dr. Handy] And you can read"},{"startTime":462.494,"endTime":464.636,"body":"more about this in Harrison's"},{"startTime":464.636,"endTime":467.652,"body":"chapter on vascular injury to"},{"startTime":464.636,"endTime":467.652,"body":"the kidney and scleroderma."},{"startTime":467.652,"endTime":471.943,"body":"[upbeat outro music]"},{"startTime":471.943,"endTime":474.81,"body":"[Mr. Shanahan] This is Jim"},{"startTime":471.943,"endTime":474.81,"body":"Shanahan, publisher at McGraw Hill."},{"startTime":474.81,"endTime":476.43,"body":"Harrison's PodClass is brought to you"},{"startTime":476.43,"endTime":478.41,"body":"by McGraw Hill's AccessMedicine,"},{"startTime":478.41,"endTime":480.494,"body":"the online medical resource that delivers"},{"startTime":480.494,"endTime":483.744,"body":"the latest trusted content from"},{"startTime":480.494,"endTime":483.744,"body":"the best minds in medicine."},{"startTime":483.744,"endTime":486.263,"body":"Go to accessmedicine.com to learn more."}]}