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Renal Hypertension

Renal hypertension causes systemic hypertension and thus has serious consequences if left untreated. It is diagnosed by assessing the patient's history, risk factors, physical findings, laboratory tests, and imaging studies.


Presentation

Renal hypertension, a cause of systemic hypertension, is the result of stenosis or occlusion in the renal artery/arteries and the subsequent under perfusion of one or both kidneys [1]. 90% of cases are caused by atherosclerotic renal artery stenosis (ARAS), which affects males above the age of 50 years while the remaining are secondary to fibromuscular dysplasia (FMD), which is commonly found in younger women [2] [3].

While some patients are asymptomatic, headache is the most frequent manifestation in others. Further complaints include emesis, visual disturbances, and changes in the mental status. If the patient has developed congestive heart failure, the clinical presentation consists of fatigue, dyspnea on exertion, peripheral edema, palpitations, and other associated symptoms [4]. Moreover, individuals with renal disease are likely to exhibit hematuria and edema [4].

There are numerous risk factors for renal hypertension such as malignant hypertension, progressive renal impairment, diastolic blood pressure greater than 120 mm Hg, hypertension unresponsive to multidrug therapy, and worsening blood pressure with diuretic use. Furthermore, hypertension accompanied by proteinuria and azotemia is another risk.

Patients with renal hypertension typically have a history of 1) a sudden increase in blood pressure, 2) onset of hypertension in the absence of risk factors, 3) worsening of previously controlled hypertension, 4) repeat episodes of pulmonary edema, 5) unprovoked hypokalemia, 6) generalized atherosclerosis in older individuals, and/or 7) smoking,

Complications

Sequelae include chronic hypertension, kidney disease, renal failure, heart failure, seizures, encephalopathy, coma, and even death. Also, end-organ damage is a concern especially in the setting of chronic kidney disease [5] [6].

Renal Artery Stenosis
  • Imaging Intra-arterial digital subtraction angiography (DSA) is currently recommended as the initial study in the assessment of renal artery stenosis, especially in patients with renal impairment.[symptoma.com]
  • Abstract Hypertension secondary to segmental renal ischemia caused by segmental renal artery stenosis has been relieved by nephrectomy, partial nephrectomy, excision of atrophic segments, or repair of the segmental vessels.[ncbi.nlm.nih.gov]
  • These were 4 cases of unilateral renal artery stenosis, 6 cases of unilateral pyelonephritis and one case of bilateral pyelonephritis with atherosclerosis of the right renal artery.[ncbi.nlm.nih.gov]
  • Abstract PG A1, B1, E2, F1,2alpha and PRA have been measured in 8 hypertensive patients with unilateral renal arterial stenosis, 7 hypertensive patients with unilateral renal atrophy and 20 control normotensive subjects.[ncbi.nlm.nih.gov]
  • After surgical treatment of the patients with atherosclerotic renal artery stenosis, fibromuscular dysplasia or pheochromocytoma, no change in erythrocyte SLC activity was observed. However, blood pressure was significantly reduced.[ncbi.nlm.nih.gov]
Resistant Hypertension
  • Data from the NHANES2 shows that 12.8% of drug-treated hypertension patients (n 539) meet the criteria for resistant hypertension.[af-ablation.org]
  • CONCLUSION: MDCT is widely used for renal artery evaluation in patients with resistant hypertension.[ncbi.nlm.nih.gov]
  • The commonest presentation of FMD is renovascular hypertention; usually grade 2–3, or resistant hypertension.[bmcresnotes.biomedcentral.com]
  • Resistant Hypertension: Comparing hemodynamic management to specialist care. Hypertension. 2002; 39 :982–988. [ PubMed ] 23. Davis BA, Crook JE, Vestal RE, Oates JA.[ncbi.nlm.nih.gov]
Fatigue
  • If the patient has developed congestive heart failure, the clinical presentation consists of fatigue, dyspnea on exertion, peripheral edema, palpitations, and other associated symptoms.[symptoma.com]
Abdominal Bruit
  • One remarkable finding in nearly 50% of affected individuals is an abdominal bruit, especially when present during both diastole and systole. Target-organ effects of chronic hypertension should also be investigated.[symptoma.com]
  • Abdominal bruits serve as a clinical sign of vascular stenosis. Difference in kidney size or unexplained renal insufficiency also raises clinical suspicion.[clinicaladvisor.com]
Hypertension
  • Intracellular K concentration was 94.3 /- 3.1 mmol/l in normotensives, 94.7 /- 3.8 mmol/l in essential hypertensives and 93.8 /- 3.9 mmol/l in renal hypertensives.[ncbi.nlm.nih.gov]
  • Abstract Renal hypertension is one of the earliest and the most prevalent complications of pediatric chronic kidney disease (CKD). Among renal patients, hypertension is frequently underdiagnosed and undertreated.[ncbi.nlm.nih.gov]
  • Due to very different (perhaps psychosocially triggered) conditions, essential hypertension leads to a stronger cardiovascular reaction under mental stress than renal hypertension.[ncbi.nlm.nih.gov]
  • Patients with renal hypertension typically have a history of 1) a sudden increase in blood pressure, 2) onset of hypertension in the absence of risk factors, 3) worsening of previously controlled hypertension, 4) repeat episodes of pulmonary edema, 5)[symptoma.com]
  • This finding, which is in contrast to earlier results indicating a lowered Ca2 ATPase activity in essential hypertension, may be explained as a consequence of an increased Ca2 influx in essential hypertension.[ncbi.nlm.nih.gov]
Kidney Failure
  • Uncontrolled hypertension may result in fatal heart attack, heart failure, kidney failure, blocked arteries in arms or legs, stroke, eye damage or poor quality of life.[cincinnatikidneydocs.com]
  • Learn about this topic in these articles: description In hypertension …but death from stroke or renal (kidney) failure is also frequent.[britannica.com]
  • If the blockage becomes severe, blood to the kidney may stop flowing altogether resulting kidney failure.[inovaheart.org]
  • This refers to high blood pressure caused by kidney disease or kidney failure. Here are the basics of renal hypertension—its causes, symptoms and forms of treatment.[reverehealth.com]
  • What groups are at risk for kidney failure related to high blood pressure? All racial groups have some risk of developing kidney failure from high blood pressure.[kidneyurology.org]
Headache
  • We report a 40-year-old lady who presented with severe headaches, persistent microscopic haematuria and hypertension requiring anti-hypertensive medication. Investigations for secondary hypertension were all normal except for a CT scan.[ncbi.nlm.nih.gov]
  • While some patients are asymptomatic, headache is the most frequent manifestation in others. Further complaints include emesis, visual disturbances, and changes in the mental status.[symptoma.com]
  • Occasionally patients with high blood pressure feel following symptoms: Confusion Headache Double or blurry vison Pink-colored urine Nosebleed Treatments for Renal Hypertension Medication is usually the first line of defense to keep blood pressure in[cincinnatikidneydocs.com]
  • Those with severe renal hypertension may experience the following symptoms: Headache and double vision Blood in urine Nosebleed Confusion Renal hypertension is dangerous because it can cause chronic kidney disease, a condition in which symptoms aren’t[reverehealth.com]
  • Older children may complain of headache and lethargy. Complications arising from severe hypertension e.g., left ventricular failure, neurological complications like Bell’s palsy, seizures or intracranial bleeds may be seen at presentation.[indianpediatrics.net]

Workup

Individuals with a clinical presentation or a history as described above warrant a full workup. The assessment consists of the patient's personal and family history, physical exam, and the appropriate studies.

Physical exam

The patient's blood pressure and other vitals must be assessed with the proper techniques in order to ensure accuracy. Very importantly, the patient should be examined carefully. One remarkable finding in nearly 50% of affected individuals is an abdominal bruit, especially when present during both diastole and systole [7] [8].

Target-organ effects of chronic hypertension should also be investigated. For example, patients with heart failure will exhibit peripheral edema and other cardiovascular signs while those with ophthalmologic manifestations will have retinal hemorrhages and retinopathy.

Laboratory tests

A complete blood count (CBC) and a complete metabolic panel (CMP), which includes electrolyte levels and renal function tests, are important components of the workup [4]. Fasting glucose and fasting lipid tests are indicated in children with chronic kidney disease, individuals with severely elevated blood pressures, and other groups as well [4]. To examine rare causes of hypertension, a 24-hour urine collection can be used to measure creatinine, electrolytes and other metabolites [4].

Imaging

Intra-arterial digital subtraction angiography (DSA) is currently recommended as the initial study in the assessment of renal artery stenosis, especially in patients with renal impairment. Along with DSA, renal arteriography is also the gold standard diagnostic technique.

Magnetic resonance angiography (MRA) offers critical information regarding the renal arteries, their branches, anatomic variants, distal stenosis, and any suspicious masses. One meta-analysis study reports that gadolinium-enhanced MRA is associated with a 97% sensitivity and 85% specificity for detection of renal artery stenosis [9]. Computed tomographic angiography (CTA) is also another technique used to diagnose stenosis.

Multidetector contrast tomography (MDCT) provides details about the renal artery and parenchyma of the kidneys as well nearby structures [10]. Another study is doppler ultrasonography, which allows for the evaluation of the anatomy and function of the renal arteries. This modality is associated with good sensitivity and specificity for detection of stenosis [11]. Additionally, a nuclear renal scan can be used to determine if a patient will benefit from surgery [12]. This test can be used with captopril for enhancement.

Small Kidney
  • Patients with unilateral (non-vascular) small kidney and patients with unilateral hydronephrosis showed comparable high cure rates (53% and 50%, respectively), whereas in no patient with a unilateral renal cyst did postoperative blood pressure return[ncbi.nlm.nih.gov]

Treatment

  • No side effects occurred during treatment except for one case of reversible acute renal failure in a transplanted patient with renal artery stenosis.[ncbi.nlm.nih.gov]
  • OBJECTIVE: This study investigated the effectiveness of unilateral nephrectomy in the treatment of renal hypertension in adults with an atrophic kidney, and set out to establish whether this is an appropriate mode of treatment for renal hypertension not[ncbi.nlm.nih.gov]
  • Abstract The effects of 6 weeks of treatment with captopril on the renal hemodynamics of 16 patients with treatment-resistant renal hypertension (six had diabetic nephropathy, seven had other renal parenchymatous disease, and three had renovascular disease[ncbi.nlm.nih.gov]
  • These results suggest that carvedilol is a useful and safe drug for the treatment of renal hypertension.[ncbi.nlm.nih.gov]
  • If the safety of enalapril is confirmed in long-term studies, the drug will clearly assume a prominent role as either first- or second-step (in combination with a diuretic) therapy in the treatment of hypertension.[ncbi.nlm.nih.gov]

Prognosis

  • The increasing use of such potent antihypertensive agents as the angiotensin I converting enzyme inhibitors has empha sized the problem of renal artery stenosis in older patients with wide spread vascular disease as well as improving the prognosis of[springer.com]
  • […] renal artery dissection (e.g. from trauma or aortic dissection ) renal infarction Page kidney renal artery embolism or thrombosis EVAR stent graft encircling tumor (e.g. pheochromocytoma ) radiation-induced fibrosis polyarteritis nodosa Treatment and prognosis[radiopaedia.org]
  • Atherosclerotic renovascular disease in United States patients aged 67 years or older: risk factors, revascularization and prognosis. Kidney Int. 2005; 68 :293–301. [ PubMed ] 18. Textor SC, Lerman LO. Renal Artery Disease: Pathophysiology.[ncbi.nlm.nih.gov]

Etiology

  • The etiology, presentation, and management are presented. Follow-up varied from 2 to 14 years and the outcome is discussed.[ncbi.nlm.nih.gov]
  • No clear-cut relation was found between response of blood pressure and etiology, degree of HT or plasma renin activity (PRA).[ncbi.nlm.nih.gov]
  • Using samples from the main renal veins we found no significant difference in renin activity and, therefore, the etiology of the hypertension in these 2 patients would have been missed.[ncbi.nlm.nih.gov]
  • ETIOLOGY RENAL STENOSIS  Decrease in the diameter of the renal arteries  Atherosclerosis; fat, cholesterol, calcium and other material found in the blood  Fibromuscular dysplasia; abnormal development or growth of cells on the renal artery walls Fibromuscular[slideshare.net]
  • The role of ROS in the main types of hypertension of renal etiology (renovascular hypertension, diabetic nephropathy, glomerulonephritides, renal tubulointerstitial diseases, end-stage renal disease) is separately approached.[tmj.ro]

Pathophysiology

  • PATHOPHYSIOLOGY 2 ways: 1. Increased renal vascular resistance 2.[slideshare.net]
  • The propensity for angiotensin receptor blockers (ARBs) to affect GFR adversely is based on similar pathophysiology.[emedicine.medscape.com]
  • Br Med J 299:703–706 CrossRef Google Scholar Jacobson HR (1991) Chronic renal failure: pathophysiology.[link.springer.com]
  • Renal Artery Disease: Pathophysiology. In: Creager MA, Dzau VJ, Loscalzo J, editors. Vascular Medicine: A companion to Braunwald's Heart Disease. Saunders-Elsevier; Philadelphia: 2006. pp. 323–334. 19. Stamey TA, Nudelman JJ, Good PH, et al.[ncbi.nlm.nih.gov]

Prevention

  • In rats with 5/6 nephrectomy, the turnover rate of norepinephrine was increased in brain nuclei involved in the noradrenergic control of blood pressure, and dorsal rhizotomy prevented hypertension.[ncbi.nlm.nih.gov]
  • Two opportunities for preventing renal hypertension are offered: chronic pyelonephritis and radiation nephritis. Received June 11, 1962. Accepted September 24, 1962.[pediatrics.aappublications.org]
  • Search Articles Contraception - A Safe And Healthy Choice For A Happy Family CONTRACEPTION – A SAFE AND HEALTHY CHOICE FOR A HAPPY FAMILY Contraception is a term for various methods to prevent conception and thus regulate...[columbiaasia.com]
  • Information for patients Blood pressure control is critically important in preventing further kidney deterioration in many patients with CKD and for protecting against damage to heart and arteries.[renal.org]
  • Learn more » Vascular Surgery Offering comprehensive care of vascular disease through preventive services, diagnostic expertise, minimally invasive therapies and traditional surgical techniques.[surgery.usc.edu]

References

Article

  1. Dillon MJ. The diagnosis of renovascular disease. Pediatr Nephrol. 1997;11(3): 366–72.
  2. Mehta AN, Fenves A. Current opinions in renovascular hypertension. Proc (Bayl Univ Med Cent). 2010;23(3): 246-9.
  3. Safian RD, Textor SC. Renal-artery stenosis. N Engl J Med. 2001;344(6): 431–42.
  4. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Pediatrics. 2004;114(2): 555-76.
  5. Mitsnefes MM, Daniels SR, Schwartz SM, Khoury P, Strife CF. Changes in left ventricular mass in children and adolescents during chronic dialysis. Pediatr Nephrol. 2001;16(4):318–23.
  6. Mitsnefes MM, Kimball TR, Witt SA, et al. Left ventricular mass and systolic performance in pediatric patients with chronic renal failure. Circulation. 2003;107(6):864–68.
  7. Kaplan NM. Renal vascular hypertension. In: Kaplan NM, Lieberman E, eds. Clinical hypertension. 7th ed. Baltimore: Williams & Wilkins; 1998; 301–21.
  8. Pohl M. Renal artery stenosis, renal vascular hypertension, and ischemic nephropathy. In: Schrier RW, Gottschalk CW, eds. Diseases of the kidney. 6th ed. Boston: Little, Brown; 1997:1367–423.
  9. Tan KT, van Beek EJ, Brown PW, et al. Magnetic resonance angiography for the diagnosis of renal artery stenosis: a meta-analysis. Clin Radiol. 2002;57(7): 617–24.
  10. Tsai IC, Chen MC, Lee WL, et al. Comprehensive evaluation of patients with suspected renal hypertension using MDCT: from protocol to interpretation. AJR Am J Roentgenol. 2009;192(5): W245-54.
  11. Strandness DE Jr. Duplex imaging for the detection of renal artery stenosis. Am J Kidney Dis. 1994;24(4):674–78.
  12. Hartman RP, Kawashima A. Radiologic evaluation of suspected renovascular hypertension. Am Fam Physician. 2009;80(3):273-79.

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Last updated: 2019-07-11 21:29