Secondary hypertension
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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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SECONDARY HYPERTENSION

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Secondary hypertension

SECONDARY HYPERTENSION


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 major target organ manifestations

Hypertension in parenchymal renal disease: major target organ manifestations


Hypertension in parenchymal renal disease

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 mr angiography 3d reconstruction

RENAL ARTERY EVALUATION:MR angiography (3D-reconstruction)


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


What is your diagnosis

What is your diagnosis ?


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


Frequency of signs and symptoms of pheochromocytoma

PHEOCHROMOCYTOMA“the great mimic”

Frequency of signs and symptoms (%) of pheochromocytoma


Secondary hypertension

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)


Secondary hypertension

PHEOCHROMOCYTOMA

Sensitivity and specifity of biochemical tests for diagnosis of pheochromocytoma


Secondary hypertension

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


Secondary hypertension

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;


Secondary hypertension

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.


Secondary hypertension

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).


Secondary hypertension

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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