PP.21.20

Abstract

Objective: A 76 years old man accessed the Emergency Department for general discomfort associated with hypertensive urgency (systolic BP > 200 mm Hg). In anamnesis: treated but poorly controlled hypertension and severe, non-proteinuric chronic kidney disease (last creatinine: 2.32 mg/dl). Patient also suffered from exudative macular degeneration with neovascularization (AMD) treated with repeated intravitreal injections of anti-VEGF agents: first Bevacizumab, then Aflibercept, a soluble decoy receptor fusion protein, named VEGF-Trap, created by fusing domain 1 of human VEGF receptor 1 to domain 3 of human VEGF receptor 2, both than fused to the constant region of human IgG1. Aflibercept has high binding affinities to all isoforms of VEGF as well as to the PLGF and it was administered two days before the ED access. Design and method: The study revealed primary hyperaldosteronism with low potassium despite marked reduction of the renal function (creatinine: 3.8 mg/dl, eGFR: 15 ml/min/1.73 mq), and proteinuria (1.5 g/24 hours). LV concentric hypertrophy, grade 1diastolic dysfunction, ectasia of the ascending aorta. ABPM results: 24 hour average BP: 144/84 mmHg despite multiple drugs. Results: After suspension of Aflibercept administration and after anti-hypertensive therapy adjustment, based on kidney function, we obtained a prompt reduction of blood pressure (24 hour average BP on a repeated ABPM: 117/67 mmHg) with disappearance of proteinuria. Conclusions: Anti-VEGF agents represent a cornerstone in the treatment of various solid tumors (intravenous administration) and AMD (intravitreal). When administered systemically they represent a well established cause of hypertension and proteinuria. Although the incidence of systemic adverse events by intraocular administration of anti-VEGF is low, in the context of an elderly patient with aldosteron-dependent hypertension and impaired renal function, intravitreal administration of Aflibercept caused hypertensive urgency with acute kidney injury and proteinuria. To confirm this, his suspension led to resolution of proteinuria and return to the basal values of eGFR. A limitation of this case, reported to the Italian Medicines Agency (AIFA report N. 242934) as the first of its kind, to the best of our knowledge, is the fact that nephrologists did not consider appropriate to perform a renal biopsy.