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SECONDARY HYPERTENSION. DEFINITION. Essential, primary, or idiopathic hypertension is defined as high BP in which secondary causes or mendelian (monogenic) forms are not present High BP – repeatedly measured BP exceeding 140/90 mmHg, i.e. a systolic BP above 140 and/or diastolic BP above 90.

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definition
DEFINITION
  • Essential, primary, or idiopathic hypertension is defined as high BP in which secondary causes or mendelian (monogenic) forms are not present
  • High BP – repeatedly measured BP exceeding 140/90 mmHg, i.e. a systolic BP above 140 and/or diastolic BP above 90
aetiology of hypertension
Aetiology of Hypertension
  • Primary – 90-95% of cases – also termed “essential” of “idiopathic”
  • Secondary – about 5% of cases
    • Renal or renovascular disease
    • Endocrine disease
      • Phaeochomocytoma
      • Cushings syndrome
      • Conn’s syndrome
      • Acromegaly and hypothyroidism
    • Coarctation of the aorta
    • Iatrogenic
      • Hormonal / oral contraceptive
      • NSAIDs
aetiology of hypertension1
Aetiology of Hypertension
  • Primary – 90-95% of cases – also termed “essential” of “idiopathic”
  • Secondary – about 5% of cases
    • Renal parenchymal (2-5%)

or renovascular disease

    • Endocrine disease
      • Phaeochomocytoma
      • Cushing syndrome
      • Conn syndrome
      • Acromegaly and hypothyroidism
    • Coarctation of the aorta
    • Iatrogenic
      • Hormonal / oral contraceptive
      • NSAIDs
renal parenchymal disease
Renal parenchymal disease
  • Acute and chronic glomerulonephritis
  • Polycystic kidney disease
  • Diabetic nephropathy
  • Pyelonephritis
  • Obstructive uropathy
  • Neoplasms
  • Renal trauma
  • Radiation nephritis
renal parenchymal disease1
Renal parenchymal disease

CIN – chronic interstitial nephritis; APKD – adult-onset polycystic kidney disease; MCN - minimal change nephropathy; MGN – membranous glomerulonephritis; DN – diabetic nephropathy; MPGN – membranoproliferative glomerulonephritis; FSGN – focal segmental glomerulonephritis

candidate pathophysiologic mechanisms related to hypertension in parenchymal renal disease
Candidate pathophysiologic mechanisms related to hypertension in parenchymal renal disease
hypertension in parenchymal renal disease conclusions
Hypertension in parenchymal renal disease:CONCLUSIONS
  • Hypertension may result from renal disease that reduces functioning nephrons;
  • Evidence shows a clear relationship between high blood pressure and end-stage renal disease;
  • BP should be controlled to 130/85 mmHg (125/75 mmHg in patients with proteinuria in excess of 1g/24 h)
aetiology of hypertension2
Aetiology of Hypertension
  • Primary – 90-95% of cases – also termed “essential” of “idiopathic”
  • Secondary – about 5% of cases
    • Renal parenchymal

or renovascular disease (0.3-3%)

    • Endocrine disease
      • Phaeochomocytoma
      • Cushings syndrome
      • Conn’s syndrome
      • Acromegaly and hypothyroidism
    • Coarctation of the aorta
    • Iatrogenic
      • Hormonal / oral contraceptive
      • NSAIDs
renal artery stenosis ras
RENAL ARTERY STENOSIS(RAS)
  • Atherosclerotic RAS (>90% of cases): involves the ostium and the proximal portion of the main renal artery with plaque extending into the perirenal aorta
  • Fibromuscular dysplasia (10% of cases): typically seen in young and middle-aged females. As opposed to atherosclerotic RAS, fibromuscular dysplasia typically affects the distal two thirds of the main renal artery
renal artery stenosis screening and diagnostic studies
RENAL ARTERY STENOSIS:screening and diagnostic studies
  • Renal duplex sonography
  • Magnetic resonance angiography
  • Renal artery arteriography
  • Captopril renography
renal artery stenosis renal duplex sonography
RENAL ARTERY STENOSIS:renal duplex sonography

Stenoses over 60%:

  • Peak systolic velocity (PSV) >150-180 cm/sec
  • Renal-aortic ratio >3.5

Prognostic value:

  • Resistance index (RI):

RI=(1-EDV)/PSVx100;

if RI>80 no benefit after revascularization

renal artery stenosis mr angiography
RENAL ARTERY STENOSIS:MR angiography

Strong sides:

  • Provides images of the renal arteries, 3D-reconstruction, plaque characterization and hemodynamic information
  • Gadolinium (contrast agent): non-nephrotoxic

Weak sides: high cost and limited availability

renal artery evaluation contrast angiography the gold standard
RENAL ARTERY EVALUATION:contrast angiography (the “gold” standard)

Fibromuscular dysplasia:

“string of beads” appearance

Atherosclerotic RAS with

poststenotic dilatation

renal artery stenosis treatment
RENAL ARTERY STENOSIS:treatment
  • BP control
  • Antiplatelet, lipid-lowering therapy, and beta-blockers, if appropriate
  • No ACE-inhibitors in severe RAS !
renal artery stenosis treatment1
RENAL ARTERY STENOSIS:treatment

Percutaneous or surgical revascularization, if:

● Resistant or poorly controlled hypertension and unilateral or bilateral renal artery stenosis

● Renal artery stenosis and recurrent flash pulmonary edema for which there is no readily explainable cause

● Chronic renal failure and bilateral renal artery stenosis or renal artery stenosis to asolitary functioning kidney

● Sonographic renal longitudinal length >7cm

aetiology of hypertension3
Aetiology of Hypertension
  • Primary – 90-95% of cases – also termed “essential” of “idiopathic”
  • Secondary – about 5% of cases
    • Renal or renovascular disease
    • Endocrine disease
      • Phaeochomocytoma (0.1-0.6 %)
      • Cushings syndrome
      • Conn’s syndrome
      • Acromegaly and hypothyroidism
    • Coarctation of the aorta
    • Iatrogenic
      • Hormonal / oral contraceptive
      • NSAIDs
pheochromocytoma frequently searched for but rarely found
PHEOCHROMOCYTOMA“frequently searched for, but rarely found”
  • About 90 % of pheochromocytomas are located within the adrenal glands;
  • 10% are bilateral;
  • 10% are malignant;
  • 10% are extra-adrenal;
  • Extra-adrenal pheochromocytomas develop in paraganglion chromaffin tissue of the sympathetic nervous system; of them, 40% are not diagnosed, 5% are multiple;
  • overall, nearly 98% of pheochromocytomas are found in the abdomen
slide27

PHEOCHROMOCYTOMAdiagnostic techniques

  • Biochemical tests
  • High pressure liquid chromatography:
  • Plasma catecholamines: noradrenaline, adrenaline;
  • Free plasma fractionated metanephrines: normetanephrine, metanephrine;
  • Urinary catecholamines (24h)
  • Urinary fractionated metanephrines (24h)
  • Spectrophotometry:
  • Total metanephrines (24h urine);
  • Vanillylmandelic acid(24h urine)
slide28

PHEOCHROMOCYTOMA

Sensitivity and specifity of biochemical tests for diagnosis of pheochromocytoma

slide29

PHEOCHROMOCYTOMAimaging techniques

  • Duplex sonography;
  • Magnetic resonance imaging (MRI);
  • Computed romography (CT);
  • 123I – meta-iodo-benzyl-guanidine scanning (123I-MIBG)
pheochromocytoma
PHEOCHROMOCYTOMA

Sonography :

  • Sonographic appearances are those of a well-defined homogeneous hypoechoic mass in approximately 50 pet cent of patients.
  • However the mass may be complex or even cystic (16 pet cent) and hyperechoic to the renal parenchyma (approximately 20 pet cent).
pheochromocytoma1
PHEOCHROMOCYTOMA

MRI (coronal and sagittal sections):

  • Magnetic resonance (MR) imaging is equally sensitive to CT and lends itself to in vivo tissue characterization, which is not possible with CT;
  • MR imaging is nearly 100% sensitive and around 70% specific.
  • Preferred for the localisation of extra-adrenal tumours or tumours during pregnancy, in children, or in patients with allergies to contrast
pheochromocytoma2
PHEOCHROMOCYTOMA

CT:

  • accurately detects tumors larger than 1.0 cm and has a localization precision of approximately 98%, although it is only 70% specific;
  • since CT scanning and MRI have similar sensitivities (90–100%) and specificities (70–80%), MRI is the preferred procedure
pheochromocytoma3
PHEOCHROMOCYTOMA

123I-MIBG scanning:

  • increased specificity (95–100%), as compared with CT or MRI;
  • provides both anatomic and functional characterization;
  • Relevant in patients with multiple, extra-adrenal, malignant (metastatic) tumors
slide34

PHEOCHROMOCYTOMA: laparoscopic removal

Preoperative Management (10-14 days)

  • Purpose:to prevent catecholamine induced, serious, and potentially life-threatening complications during surgery, including hypertensive crises, cardiac arrhythmias, pulmonary oedema, and cardiac ischemia;
  • BP should be reduced to below 160/90 mm Hg for at least 24h;
  • orthostatic hypotension should be present, but blood pressure in the upright position should not fall below 80/45 mm Hg;
  • there should be no more than one ventricular extrasystole every 5 min;
  • and the electrocardiogram should show no S-T segment changes and T-wave inversions for 1 week;
slide35

PHEOCHROMOCYTOMA:

Management

  • Phenoxybenzamine, a long acting alpha-adrenergic blocker, is the mainstay of medical treatment to control BP. A total dose of 1 mg/kg is sufficient in most patients.
  • An alpha-blocker Doxazosin in increasing doses from 1 to 16 mg once a day.
  • A beta-adrenoceptor blocker (eg,propranolol 40 mg three times daily or atenolol 25–50 mg once daily) could be included after several days of alpha-adrenergic blockade.
  • Adequate salt and fluid intake lowers the risk of orthostatic hypotension.
slide36

PHEOCHROMOCYTOMA:

Management

  • Should substantial rises in blood pressure still take place during surgery, these can be controlled by bolus or by continuous infusion of phentolamine, sodium nitroprusside, or a shortacting calcium antagonist (eg, nicardipine);
  • Tachyarrhythmias can be treated by infusion of a shortacting -adrenoceptor blocker (eg, esmolol).
slide37

PHEOCHROMOCYTOMA

Sensitivity and specifity of biochemical tests for diagnosis of pheochromocytoma

conn s syndrome primary hyperaldosteronism
Conn’s Syndrome (primary hyperaldosteronism)
  • Should be considered in any hypertensive pt with muscle weakness, polydipsia, andor hypokalemia;
  • 75% - adrenal adenoma;
  • 25% - adrenal hyperplasia
  • Rarely – adrenocortical cancer
primary hyperaldosteronism
Primary Hyperaldosteronism
  • Screening for hyperaldosteronism should include plasma aldosterone and plasma renin activity

measured in morning samples

  • Plasma aldosterone:renin ratio: normally <20;

diagnostic cut-off value >30;

  • Aldosterone excretion rate during salt loading, captopril, or spironolactone test (the captopril test may be less useful in blacks because of the high prevalence of low plasma renin activity)
  • Adrenal CT, MRI
primary hyperaldosteronism1
Primary Hyperaldosteronism

Should be differentiated from

  • Secondary hyperaldosteronism in patients with renal failure, CHF, essential hypertension
  • Monogenic forms of hypertension (pseudohyperaldosteronism):
  • Liddle’s syndrome (autosomal-dominant disorder, characterized by low-renin, low-aldosterone, low-potassium volume-expanded hypertension)
  • Gordon’s syndrome (autosomal-dominant disorder, characterized by low-renin, low-aldosterone, high-potassium volume-expanded hypertension)
primary hyperaldosteronism2
Primary Hyperaldosteronism

TREATMENT

1. Medical

  • Spironolactone, a competitive aldosterone antagonist
  • Amiloride, a potassium-sparing diuretic
  • Glucocorticoids (in glucocorticoid-remediable form)

2. Surgical, if appropriate

aetiology of hypertension4
Aetiology of Hypertension
  • Primary – 90-95% of cases – also termed “essential” of “idiopathic”
  • Secondary – about 5% of cases
    • Renal or renovascular disease
    • Endocrine disease
      • Phaeochomocytoma
      • Cushing’s syndrome (0.1-0.6%)

Conn’s syndrome

      • Acromegaly and hypothyroidism
    • Coarctation of the aorta
    • Iatrogenic
      • Hormonal / oral contraceptive
      • NSAIDs
cushing s syndrome
Cushing’s Syndrome
  • Hypertension occurs in about 80% of patients;
  • Urinary free cortisol
  • If 24h UFC>100 µg/ml: measure plasma ACTH
hypothyroidism
Hypothyroidism
  • Both hypertension (particularly diastolic) and hypotension are common;

Hyperthyroidism

  • Accompanied by systolic hypertension, especially in the elderly;

Acromegaly

  • 25-50% exhibit elevated blood pressure
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