Extracorporeal methods in the management of severe and malignant arterial hypertension.

Abstract

Novel approaches to managing refractory arterial hypertension (AH) have been tested in 130 patients aged 28 to 59 years with severe or malignant hypertension. Hemosorption was performed in 70 patients in whom AH was caused by chronic diffuse glomerulonephritis (49 cases) or chronic pyelonephritis (21 cases) accompanied by the appearance of chronic renal failure. In all patients, blood pressure after hemosorption decreased by 15% to 16% on the average, resulting in progressively improved renal function and a nearly 2.0-fold reduction in plasma aldosterone concentration (PAC), and allowing the doses of antihypertensive drugs to be reduced. Plasmapheresis was performed in 31 patients with refractory severe or malignant AH due to essential hypertension or parenchymatous diseases of the kidneys. After two to four plasmapheresis sessions with up to 2 L of plasma exchanged, blood pressure dropped by 24% compared to baseline while the doses of antihypertensive drugs were diminished and some were discontinued completely in several cases. Analysis of the sensitivity to antihypertensive drugs after plasmapheresis using the rosette technique revealed a significant decrease in the number of rosette-forming cells. The level of angiotensin II and urinary excretion of aldosterone-18-glucuronide declined progressively by nearly 50% after plasmapheresis, correlating with the antihypertensive effect of plasmapheresis. In 32 patients with severe AH complicated by refractory cardiac failure, isolated ultrafiltration was used. After one to eight sessions and the removal of 1.0 L to 35.8 L of fluid, the signs of cardiac failure diminished, the blood pressure level responded to drug therapy, and the PAC level decreased significantly. Although the mechanisms of the antihypertensive actions of hemosorption, plasmapheresis, and isolated ultracentrifugation are still not completely elucidated, these data suggest that hemosorption may act by removing nitrogenous residues from the body and reducing PAC, plasmapheresis by deblocking receptors for antihypertensive drugs and reducing the concentration of angiotensin II and the synthesis of aldosterone in the body, and isolated ultrafiltration by eliminating hyperhydration and edema of the parenchymatous organs.