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Transcript of HTN &Renal vascular disorders Ebadur Rahman FRCP (Edin),FRCPI,FASN, Specialty Certificate in...
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HTN &Renal vascular disorders
Ebadur RahmanFRCP (Edin),FRCPI,FASN, Specialty Certificate in Nephrology (UK)MRCP (UK), DIM (UK), DNeph (UK), MmedSciNephrology (UK).
Consultant & clinical tutorDepartment of NephrologyRiyadh Armed Forces Hospital
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Definition
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Impact of Hypertension• 50 million individuals in
the United States have hypertension1
• 277,000 deaths annually in US due to hypertension2
1American Association of Clinical Endocrinologists Medical Guidelines For Clinical Practice for the Diagnosis and Treatment of Hypertension. Endocrine Practice, Vol 12 No. 2 March/April 20062National Center for Health Statistics. Health, United States, 2005, with Chartbook on the Health of Americans. Hyattsville, Maryland: 2004. Available at: http://www.cdc.gov/nchs/hus.htm
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Consequences of Hypertension
Hypertension
Brain
Heart
Kidney End-stage renal disease
MI, heart failure,sudden death
Stroke, dementia
1. Weir et al. Am J Hypertens 1999;12:205S-213S. 2. Beers MH, Berkow R, eds. The Merck Manual of Diagnosis and Therapy. 17th ed. 1999:1629-1648. 3. Francis CK. In: Izzo JL Jr, Black HR, eds. Hypertension Primer: The Essentials of High Blood Pressure. 2nd ed. 1999:175-176. 4. Hershey LA. In: Izzo JL Jr, Black HR, eds. Hypertension Primer: The Essentials of High Blood Pressure. 2nd ed. 1999:188-189.
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9
25 years
Admitted with fits BP 160/100
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Diagnosis
• Posterior reversible leuko ephalopathy
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40 years BP 150/80 normal biochemestry
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What to do
• Observe • ACE• Nephrectomy • DIURETICS• ATENOLOL
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ACE
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More than 80% essential HTN
Renal causes of hypertension (2.5-6%)
• Polycystic kidney disease • Chronic kidney disease • Urinary tract obstruction • Renin-producing tumor • Liddle syndrome
Endocrine cuases 1-2%• Primary hyperaldosteronism • Cushing syndrome • Pheochromocytoma • Congenital adrenal
hyperplasia
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58 y BP 150/100
• Calcium channel blocker • ACE• ARB• DIURETICS• ATENOLOL
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• Ace / arb
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ModificationApproximate SBP
Reduction(range)
Weight Reduction 5-10 mmHg/10kg
Adopt DASH eating plan 8-14 mmHg
Dietary sodium reduction 2-8 mmHg
Physical activity 4-9 mmHg
Moderation of alcohol consumption
2–4 mmHg
Lifestyle ModificationsLifestyle Modifications
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Resistant hypertension —16% American Heart Association
defined - uncontrolled blood pressurein spite of concurrent use of 3 antihypertensive agents blood pressure is controlled with 4/ 4+ more medications.
• one of the three agents should be a diuretic and all agents should be prescribed at optimal doses
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Pseudoresistant hypertension —20-30%
1-Inaccurate measurement of blood pressure 2-Poor adherence to antihypertensive therapy. 3-White coat hypertension.
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ISOLATED SYSTOLIC HYPERTENSION
• Defined as a systolic BP above 160 mmHg, with a diastolic BP below 90 mmHg .
• ISH mostly occurs – in olderly ( 60 - 75 % )
• ISH – anemia, – hyperthyroidism, – aortic insufficiency, – arteriovenous fistula, – Paget disease of bone .
• ISH is associated with a 2- to 4 fold increase in the risk – MI, LVH, renal dysfunction, stroke.
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Diastolic hypertension — DBP 90+Goal diastolic pressure of 85 to 90 mmHg .
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Importance of systolic & diastolic pressure —
• Among elderly patients, – HIGHER THE the systolic BP- risk coronary heart
disease
• inversely with the diastolic pressure
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MASKED HTN
• NORMAL CLINIC PRESURE BUT ABNORMAL WITH DAILY ACTIVITY
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• A 45-year-old man has just been found to have a persistently raised blood pressure. He considers himself a fit and healthy non-smoker and no other abnormalities were found during the examination.
• What investigations you would do?
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Investigations for HTN
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How often you will screen
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The prevalence of renovascular hypertension
• less than 1 % in patients with mild hypertension
• but may be as high as 10 to 40 %– severe, or refractory hypertension
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Types of RAS
• Atherosclerosis –– patients over the age of 45 years – involves the aortic orifice or the proximal main renal
artery.– common in patients with diffuse atherosclerosis
• Fibromuscular dysplasia – – fibromuscular dysplasia (FMD) most often affects women
under the age of 50 years– and typically involves the distal main renal artery or the
intrarenal branches
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•Diagnosis
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Some clinical clues
• A recent or rapid development of severe hypertension.
• sudden development of left ventricular failure (referred to as "flash pulmonary edema")
• Rapidly rising serum creatinine levels- following administration of angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs).
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Magnetic resonance angiography — MR imaging (MR angiography)
• MR angiography had a sensitivity of 100 percent and specificity of 96 percent
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Spiral CT scan with CT angiography — Spiral (helical) CT scan with intravenous contrast injec
• Spiral CT scan – sensitivity and specificity for renal artery stenosis
of 98 and 94 percent, respectively..
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Dopler
• Peak systolic velocity -specificity of 85 and 92 percent, respectively.
• It is time-consuming (taking up to two hours to perform).
• It is technically difficult, and is highly operator-dependent.
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renal vein renin
• measurements are no longer considered suitable for screening patients because of their poor sensitivity and specificity.
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Plasma renin activity —
• The baseline plasma renin activity is elevated in only 50 to 80%
• The sensitivity and specificity of the captopril renin test has ranged in different studies from 75 to 100 percent and 60 to 95 percent, respectively
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Captopril renogram —
• Oral captopril (25 to 50 mg) is given one hour before the isotope is injected . The efficacy of this test is based upon the typical ACE inhibitor-induced decline in GFR in the stenotic kidney,– accompanied by an equivalent increase in GFR in the contralateral
kidney due to removal of angiotensin II-mediated vasoconstriction.• The net effect is that the difference between the two kidneys
is enhanced.• A marker of glomerular filtration, such as DTPA, or compounds
that are secreted by the proximal tubule, such as hippurate and MAG3, have been used.
• MAG3 more reliable in patients with renal insufficiency
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• How ever most centers in US donot do this scan and preffer MRI OR CT ANGIO
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Gold standard-angiogram
• Management issues
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Three therapeutic options are available
• Medical therapy• Percutaneous angioplasty with or without
stent placement• Surgery
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Medical management
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The largest trial, ASTRAL, included 806 patients with either unilateral or bilateral atherosclerotic renal artery stenosis who were randomly assigned to either medical therapy alone or medical therapy plus revascularization
• showed no significant difference between the two groups in the rate of progression of the serum creatinine (the primary end point) at a median follow-up of almost three years.
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it is generally recommended that the following patients undergo renal artery revascularization
• Those with recent onset hypertension,• younger patients
– less likely to have underlying atherosclerotic disease,– significantly reduce the number of antihypertensive medications.
• Patients whose blood pressure cannot be lowered to the desired goal despite compliance with a reasonable medication regimen.
• Patients who are unable to tolerate antihypertensive• Patients with loss of parenchymal mass from ischemic
nephropathy.
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WHICH OF THE FOLLOWING DRUG CAN CAUSE ACUTE RENAL SHUT DOWN IN BILATERAL RAS
• LABETOLOL• AMLODIPINE• NEMODIPINE• NITROPRUSIDE• Ace/arb
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WHICH OF THE FOLLOWING DRUG CAN CAUSE ACUTE RENAL SHUT DOWN IN BILATERAL RAS
• LABETOLOL• AMLODIPINE• NEMODIPINE• NITROPRUSIDE• Ace/arb
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Surgical revascularization should be
• considered if angioplasty fails• who have multiple small renal arteries, • early primary branching of the main renal
artery, • require aortic reconstruction near the renal
arteries for other indications• aneurysm repair or severe aortoiliac occlusive
disease)
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• Thank you