Hipertensión Arterial Secundaria ¿por dónde empezar? / Secondary Arterial Hypertension, where to start?

30 to 40% of the adult population worldwide has been diagnosed with hypertension, among these patients 5 to 10% of them could have a possibly curable condition. In order to recognize this special population, the clinician must perform a complete work up and be aware of the main underlying causes of secondary hypertension. Often this could be a goal difficult to accomplish. The purpose of this article is to discuss the most frequent causes of secondary hypertension and offer a diagnostic approach for these patients. Clinicians should never forget that drug-related hypertension is a common cause that is discovered only with the help of a good medical history.

Resultados a longo prazo da angioplastia de artérias renais com stent na doença aterosclerótica: revisão sistemática / Long term outcome of renal artery angioplasty with stenting for atherosclerotic stenosis: a systematic review

A doença renovascular aterosclerótica é a principal causa de hipertensão secundária. A história natural da doença demonstra taxas de progressão de 4 a 12% ao ano. Entre os métodos de tratamento existe a angioplastia com stent de artérias renais; porém, poucos estudos clínicos demonstraram seus resultados a longo prazo. Esta revisão sistemática da literatura se propõe a apresentar os resultados a longo prazo (acima de 24 meses) da angioplastia com stent de artérias renais na doença aterosclerótica em relação à função renal e aos níveis pressóricos no controle da hipertensão. Foi realizada uma ampla pesquisa, utilizando os termos apropriados, nas bases de dados LILACS, EMBASE, SCIELO, Cochrane Library e MEDLINE. De um total de 2.170 referências, apenas sete artigos contemplavam todos os critérios de inclusão. Conclui-se que, a longo prazo, há uma estabilização da função renal, redução dos níveis pressóricos e diminuição do número de classes de medicamentos anti-hipertensivos

Atherosclerotic renovascular disease is the most important cause of secondary hypertension. The natural history of the disease reveals progression rates of 4 to 12% per year. Angioplasty with renal artery stenting is one treatment option; but there are few studies that have reported long-term results. The objective of this systematic literature review is to discuss the long-term results (at least 24 months) of angioplasty with stenting of renal arteries for atherosclerotic disease, in terms of renal function and blood pressure levels for control of hypertension. A thorough search was conducted of LILACS, EMBASE, SCIELO, Cochrane Library, and MEDLINE using the appropriate terms. Just seven out of 2170 references identified met all inclusion criteria. It was concluded that over the long term renal function was stabilized, blood pressure levels were reduced, and the number of classes of antihypertensive medication decreased

Fibromuscular dysplasia: a cause of secondary hypertension

No abstract available.

Avaliação da sensibilidade e especificidade dos exames utilizados no diagnóstico da estenose de artéria renal em prováveis portadores de hipertensão renovascular / Evaluation of sensivity and specificity of tests used in the diagnosis of renal artery stenosis in patients probably with renpovascular hypertension

A crescente incidência da aterosclerose na população adulta e a obstrução da artéria renal são condições relacionadas à hipertensão renovascular. Independente das comorbidades presentes, a estenose de artéria renal é, por si só, importante causa de mortalidade cardiovascular...

Hypertension due to angiodysplasia.

Renovascular hypertension is non essential hypertension, wherein anatomically evident arterial occlusive disease and increased blood pressures are related as cause and effect. The hypertension is due to renal ischemia. Angiodysplasia is an uncommon angiopathy associated with heterogeneous histological changes that may affect the carotid circulation and the visceral and peripheral arteries.

Hipertensión arterial renovascular / Renovascular hypertension

En este artículo se describe la hipertensión renovascular en adultos y niños, su prevalencia, sus causas más comunes, destacando las lesiones ateroescleróticas en el adulto mayor de cincuenta años. Las alteraciones fisiopatológicas, los elementos clínicos de sospecha diagnóstica, el diagnóstico por imágenes y las bases terapéuticas de esta afección.

This article describes renovascular hypertension in children and adults, the prevalence of this entity, the principal causes, with attention to atherosclerotic lesions in adults older than fifty years of age, physiopathologic changes, clinical aspects for diagnosis, imaging procedures and general treatment guidelines.

Tratamento endovascular da estenose da artéria renal em rim único / Endovascular treatment of renal stenosis in solitary kidney

CONTEXTO: O tratamento endovascular da doença renal hipertensiva, em doentes com rim único, conseqüente à estenose de artéria renal, mostrou ser efetivo na prevenção da falência do órgão, sua função e controle da hipertensão. Quando indicado após avaliação criteriosa, tanto bioquímica como por imagens e sinais do doente, o tratamento endovascular apresenta benefícios clínicos de forma efetiva e pouco invasiva. OBJETIVO: Estudar a doença hipertensiva renovascular e avaliar a eficácia do tratamento endovascular no controle da hipertensão arterial sistêmica e da insuficiência renal secundárias à estenose da artéria renal e como medida de prevenção de falência renal em doentes com rim único funcionante. MÉTODO: Estudo realizado com protocolo de atendimento previamente elaborado, no Centro de Referência de Alta Complexidade em Cirurgia Endovascular do Hospital de Clínicas da Universidade de Campinas, de abril de 1997 a junho de 2005, em 10 doentes com diagnóstico de estenose da artéria renal em rim único funcionante, submetidos ao tratamento endovascular. Foi avaliada a melhora da hipertensão e função renal através de seguimento clínico e laboratorial com medidas de pressão arterial, dosagens séricas de uréia, creatinina e clearance. Exames pelo eco-color-Doppler foram realizados no pós-operatório de 30 dias, 3 meses, 6 meses e anualmente; no caso de haver alguma dúvida na obtenção de imagens ou sinais, foi realizada a aortografia e arteriografia seletiva renal. Nesta casuística, 90 por cento dos doentes apresentavam hipertensão arterial, 70 por cento eram tabagistas, 40 por cento, hiperlipidêmicos, 30 por cento apresentavam doença oclusiva cerebral extracraniana, 60 por cento, obstrução arterial crônica nos membros inferiores, e 20 por cento, diabetes melito. RESULTADOS: O sucesso inicial foi de 100 por cento. O seguimento médio foi de 40 meses. Houve controle da pressão arterial em 90 por cento, diminuição significativa dos níveis de uréia...

BACKGROUND: Endovascular treatment of hypertensive renal disease in patients with a solitary kidney secondary to renal artery stenosis proved to be effective to prevent organ failure and function, as well as hypertension control. When indicated after judicious evaluation using both biochemical methods and the patient's images and signs, endovascular treatment has effective clinical benefits and is little invasive. OBJECTIVE: To study renal artery stenosis with hypertension and evaluate the effectiveness of endovascular treatment in the control of hypertension, renal failure secondary to renal artery stenosis, and in the prevention of renal failure in patients with a solitary kidney. METHODS: This study was performed at the Reference Center of High Complexity in Endovascular Surgery of Hospital de Clínicas da Universidade de Campinas from April 1997 through June 2005 using a previously developed protocol. Ten patients with renal artery stenosis and solitary kidney submitted to endovascular treatment were included. Improvement in hypertension and renal function was assessed through clinical follow-up and laboratory tests using measurements of blood pressure, serum urea levels, creatinine and clearance. Color-flow Doppler ultrasound was performed 30, 90, 180 days after the surgery and yearly thereafter. Aortography and selective renal arteriography were performed in case of doubt as to images or signs. For this population, 90 percent had hypertension, 70 percent were smokers, 40 percent had hyperlipidemia, 30 percent had carotid artery occlusive disease, 60 percent had chronic lower limb arterial occlusion, and 20 percent had diabetes mellitus. RESULTS: Immediate success was 100 percent. Mean follow-up time was 40 months. Control of blood pressure occurred in 90 percent of the cases, and in 10 percent there was significant reduction in urea and creatinine levels and worsening of hypertension after the procedure. CONCLUSION: Endovascular...

Hipertensão secundária - renovascular: diagnóstico e tratamento / Secondary hypertension - renovascular hypertension: diagnosis and treatment

O presente artigo revisa o importante papel do diagnóstico e tratamento da doença renovascular, que pode ou não ser causa de hipertensão arterial. Infelizmente ainda não dispomos na atualidade de evidências científicas robustas que nos orientem sobre o melhor momento e a melhor terapêutica para pacientes portadores de doença renovascular. É certo que, independentemente da opção terapêutica utilizada, além da necessidade de se alcançar melhor controle da pressão arterial e preservação da função renal, é imperativo que todas as co-morbidades presentes sejam corrigidas, quando se buscam melhores resultados finais pós-intervenção. Assim, a investigação precoce baseada em critérios clínicos de probabilidade somada ao auxílio de exames complementares permitirão maiores chances de acerto diagnóstico, cuja certeza só existirá após a realização da intervenção escolhida. Infelizmente a mesma certeza que temos nas melhores opções diagnósticas não dispomos em relação aos resultados tardios no que tange à evolução clínica dessa população. Necessário será aguardarmos os resultados de estudos em andamento e que estes possam revelar nossas maiores dúvidas quanto a melhor forma de tratamento.

Renal CT angiography with multi detector CT scaners

Multidetector row CT angiography has become an important tool in the evaluation of patients with suspected renovascular hypertension. The following article presents a review of the published data on accuracy of this method of evaluation as well as a comparison to other diagnostic strategies, in particular, renal MR angiography

A Comparison of Low-Dose and Normal-Dose Gadobutrol in MR Renography and Renal Angiography

OBJECTIVE: It has been advocated that a reduced injection volume with highly concentrated (1 M) contrast material can produce a sharper bolus peak and an increased intravascular first-pass gadolinium concentration when compared with the use of a lower concentration (0.5 M). A higher concentration would also cause a reduction in dose. The purpose of our study was to test the use of a low dose (0.05 mmol/kg) of gadobutrol in magnetic resonance renography and angiography and compare the findings with a dose of 0.1 mmol/kg. MATERIALS AND METHODS: One-hundred-thirty-four patients referred for magnetic resonance angiography for suspected renovascular disease participated in the study. Contrast enhanced MR renography and angiography were performed after administration of a bolus of 0.1 mmol/kg or 0.05 mmol/kg gadobutrol in randomized patients. The relative signal intensity-time curves of the aorta, peripheral cortex and parenchyma, were obtained. Two radiologists evaluated the angiographic images and evaluated the quality of angiography. RESULTS: The signal intensity with a low dose of gadobutrol was significantly lower in early phases, in the peripheral cortex (for 36, 54, 72 and 90 seconds), the parenchyma (for 36, 54, 72 seconds) and the aorta (for 18, 36, 54, 72 seconds). The decreases in the early phase obtained with a low dose of gadobutrol caused blunter time intensity curves. The difference in the quality scores of the readers for the angiographic images for the use of the two different doses was not statistically significant (p > 0.05). CONCLUSION: A lower dose of gadobutrol can be used for MR renal angiography, but for MR renography the normal dose should be used.

nutcracker syndrome: an underdiagnosed cause for high grade varicocele

The nutcracker syndrome represents a clinical condition caused by compression of the left renal vein [LRV] between the superior mesenteric artery [SMA] and the aorta. One of its manifestations is left-sided varicocele. The aim of this study is to determine the prevalence of nutcracker syndrome in patients with primary and recurrent high grade left-sided varicocele. Fifty patients with primary and recurrent high grade left-sided varicocele were enrolled in this study. Color Doppler ultra-sonography [US] of renal vessels was done and diameter of LRV and peak systolic velocity [PSV] were measured in renal hilum and in site of compression of LRV be-tween SMA and the aorta and then magnetic resonance angiography [MRA] of renal vessels was done. Thirty six patients [72%] had primary high grade varicocele and 14 patients [28%] had recurrent high grade varicocele. Twelve patients [33%] with primary high grade varicocele and seven patients [50%] with recurrent varicocele had evidences of NCS in color Doppler US and MRA. The differences of LRV diameter in NCS group and in patients without NCS were statistically significant [P<0.001]. The differences of PSV in the LRV at the hilar portion in the NCS group and in the patients without NCS were not statistically significant. The differences of PSV in the LRV at the aortomesenteric portion in the NCS group and in the patients without NCS were statistically significant [P< 0.001]. In all patients with NCS, MRA showed dilatation and compression of LRV at site of passage between aorta and SMA. NCS should be suspected in patients with high grade primary and recurrent varicocele

O Scan Duplex para diagnósticos de hipertensao renovascular / Scan Duplex in the diagnosis of renovascular hypertension

Objetivo: O objetivo deste estudo é de demonstrar a capacidade do SD em identificar lesões de artérias renais em pacientes com hipertensão arterial sistêmica de causa renovascular (HRV).Pacientes e métodos: Foram incluídos 39 pacientes hipertensos com suspeita de HRV avaliados pelo SD. Os seguintes parâmetros para o diagnóstico de estenose igual ou superior a 60 por cento da luz do vaso so SD: pico de velocidade sistólica no local da estenose da artéia renal igual ou superior a 180cm/s, índice renal aórtico acima de 3,5 e presença de fluxo intrarrenal alterado, com tempo de aceleração acima de 70ms e morfologia tardus parvus. Foram utilizadas, também, assimetria renal de 1,5cm e visulaização da artéria com ausência de fluxo ao Doppler e fluxo a cores para oclusão arterial. Resultados: Dos 30 pacientes examinados, seis apresentaram, critérios para estenose igual ou acima de 60 por cento ou oclusão, e foram avaliados pela angiografia, que confirmou as achados pelo SD, 12 artérias examinadas...

Recanalization of a single functioning kidney.

For patients with renal artery stenosis, percutaneous transluminal angioplasty is generally the treatment of choice. This report describes the case of an elderly lady with type III aortoarteritis whose right renal artery was successfully recalized and stented. There was satisfactory improvement in renal function and blood pressure post-procedure, and at one-month follow-up.

Shock cardiogénico por emergencia hipertensiva en un neonato / Cardiogenic shock due to hypertensive emergency in a newborn

Introducción: la hipertensión arterial (HTA) neonatal es poco frecuente, especialmente en recién nacidos previamente sanos. La presentación clínica es variable, siendo en ocasiones dramática y con riesgo para la vida del paciente. Caso clínico: comunicamos un neonato de 6 días de vida, sexo femenino, quién ingresó con shock cardiogénico y acidosis metabólica grave. Requirió ventilación mecánica y uso de inótropos por franca falla sistólica (fracción acortamiento 20 por ciento). Tras recuperación inicial destacó hipertensión arterial grave (presión sistólica 50 mmHg sobre el p95).0 ECO Doppler renal fue normal. Exámenes de laboratorio mostraron trombocitopenia, niveles elevados y mantenidos de dímero D. Su estudio cintigráfico Tc-99m MAG3 reveló retraso en la captación del contraste en los dos tercios superiores del riñón derecho. Angioresonancia renal fue normal. Hubo recuperación miocárdica y control de la presión arterial con tratamiento digitálico e inhibidores de la enzima convertidora de angiotensina, siendo dada de alta. Luego de la exclusión de otras causas, como infecciosas, hipoperfusión y anatómicas, especulamos que un evento microangiopático perinatal puede haber ocasionado la hipertensión renovascular. Conclusión: la hipertensión arterial siempre debe de ser incluida en los diagnósticos diferenciales del neonato con shock cardiogénico y acidosis, dado la gravedad con que se presenta y su diferente modalidad de tratamiento.

Renovascular hypertension.

Renovascular hypertension results from a lesion that impairs blood flow to a part or all, of one or both kidneys. 3-10% of children referred for the evaluation of severe hypertension are subsequently found to have clinically significant renovascular lesions Renovascular hypertension is the second most common cause of correctable hypertension in children second only to coarctation of the aorta. Specific therapeutic options now available, justify the often-invasive investigations required to confirm the diagnosis of renovascular hypertension. A systematic evaluation of the child with hypertension will help the pediatrician select correctly, the child most likely to have renovascular hypertension, thus reducing the number of children exposed to the risks involved with diagnostic but invasive investigations like renal arteriography which remains the gold standard Other non-invasive newer modalities like doppler ultrasonography, computed duplex sonography, ACE inhibited radionuclide imaging, and MR/CT/spiral CT angiography may be used depending on the availability of the facilities. Definite therapeutic options for renal artery stenosis include angioplasty, stenting and surgical re-vascularization using a bypass graft.

Hipertensão renovascular por displasia fibromuscular / Renovascular hypertension due to fibromuscular dysplasia

Os autores relatam um caso de hipertensão renovascular por displasia fibromuscular em paciente de 34 anos, do sexo feminino, caucasiana, encaminhada ao serviço hospitalar devido a queixa de zumbido na região cervical bilateral há aproximadamente 8 meses, mais acentuado à esquerda. Relatava, também tonteiras ocasionais e hipertensão arterial. O diagnóstico foi confirmado por arteriografia, que evidenciou lesões com aspecto em colar de contas em artérias carotidas interna, artéria renal direita e arterias iliacas externas. Este artigo tem como objetivo chamar a atenção para as doenças raras, que muitas vezes passam desapercebidas, e estimular o exercício do diagnóstico diferencial.