Cause Of Resistant Hypertension Research Articles

Impact of renal denervation on quality of life how does renal denervation contribute to improving hypertension treatment affected by poor medication adherence?

The US Food and Drug Administration has approved renal denervation (RDN) as a new treatment option for hypertension (HT) because it not only has antihypertensive effects but also improves the quality of blood pressure (BP) reduction. RDN is expected to be increasingly used in clinical practice in the future. This review summarizes the impact of RDN on quality of life (QOL). Although the treatment of HT aims to improve life prognosis, the use of antihypertensive agents can impair QOL because of adverse effects and lifestyle changes associated with long-term medication use. Consequently, poor adherence to antihypertensive agents is a common problem and may be the most important issue affecting patient QOL. In RDN trials in patients taking antihypertensive agents, approximately 40% of patients had poor adherence to the drugs. Poor adherence is often the cause of resistant hypertension. Therefore, RDN should be well suited to treating HT and improving QOL. Studies have shown that approximately 30% of HT patients prefer RDN to drug treatment. Patients who prefer RDN are typically male and younger and have high BP, poor adherence, and a history of adverse effects of antihypertensive agents. We hope that RDN will improve not only life prognosis but also QOL in HT patients because of its benefits for adherence. Furthermore, we expect that in the future, RDN will be used in other sympathetic nervous system-related diseases, such as heart failure, atrial fibrillation, and sleep apnea syndrome.

Abstract P227: Resistant Hypertension In Young Patient- A Case Of Conn’S Syndrome

Abstract: Resistant hypertension (HTN) is defined as elevated blood pressure (BP) while being on three different antihypertensive medications at maximum recommended doses which include diuretics or BP that requires four different antihypertensives. One of the secondary causes of resistant HTN is Conn's Syndrome (CS). CS is mainly due to excessive secretions of aldosterone (aldo), Aldo is a mineralocorticoid hormone that maintains sodium and potassium homeostasis. Excessive secretion can result in hypernatremia and hypokalemia. This is a case of a young patient who presented with resistant hypertension and low potassium. Case: A 47-year-old African American with a known history of HTN presented with a seizure-like episode due to elevated BP and low potassium (K) of 2.6 with a creatinine of 2.2 (baseline creatinine 1.2). He was non-compliant with BP medication hydrochlorothiazide. During hospitalization, BP remained elevated with low K even with K supplementation. BP regimen was broadened to amlodipine, carvedilol, hydralazine, losartan, and spironolactone. Further evaluation showed elevated plasma aldo and low renin with a ratio >30. CT abdomen with contrast confirmed a right adrenal gland adenoma measuring 1.8 cm x 2.0 cm. Ultimately, the patient underwent robot-assisted right adrenalectomy, and adrenal vein sampling (AVS) confirmed CS. The right AVS showed an aldo level >3000 ng/dl and the left adrenal aldo level was 37.6 ng/dl. After successful surgery, BP medicines were cut down to spironolactone. A few months later, BP improved, and all medications were discontinued. Discussion: Aldosterone poses proinflammatory, prothrombotic, and profibrotic changes that in the long-term cause end-organ damage. For these reasons, diagnosing hyperaldosteronism early in young patients is crucial to avoid further complications. Adrenalectomy is a treatment of choice in most cases, many patients could also benefit from pharmacotherapy, especially with newer medications that are not anti-androgenic and nonsteroidal like finerenone. Hyperaldosteronism can be simply diagnosed by checking serum morning aldo level and renin level. Therefore, screening for hyperaldosteronism should be done frequently in young patients with resistant HTN.

Beyond Conventional Control: Insights Into Drug-Resistant Hypertension.

It is believed that 9-18% of patients with hypertension have resistant hypertension, a serious medical disease. The increased cardiovascular risk associated with this illness demands appropriate diagnosis and treatment. It is necessary to conduct an in-depth investigation of the various etiologies, indicators of risk, and multiple disorders of resistant hypertension. This is crucial in order to establish the diagnosis and make the best decisions regarding therapy. Treatment should also take lifestyle changes into account in addition to medicinal and interventional therapy. When there is a suspicion of resistant hypertension, examining the medications used to treat the hypertensive patient after ruling out pseudo hypertension, improper blood pressure monitoring and control, and the white-coat effect are necessary. Resistant hypertension, according to a specific definition, is a condition that cannot be treated with more than two antihypertensive drugs, including a diuretic. An effective multidrug therapy for the treatment of resistant hypertension includes angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, beta-blockers, diuretics, long-acting calcium channel blockers, and mineralocorticoid receptor antagonists. However, alternative, cutting-edge treatments, such as renal denervation or baroreflex activation, could develop a brand-new avenue for decreasing blood pressure. These new surgical interventions might prove out to be of immense importance in coming times. Secondary causes of resistant hypertension, such as obstructive sleep apnea, coronary artery diseases, nephropathy, or endocrinal diseases, must be checked out in order to make an accurate diagnosis of this illness. This review article briefly summarizes the epidemiology, risk factors, causes, pathogenesis, diagnosis, and treatment approaches that may help with the long-term management of resistant hypertension.

Predictors of successful outcome after adrenalectomy for unilateral primary aldosteronism.

Unilateral primary aldosteronism (UPA) is the most frequent surgically curable form of endocrine hypertension. Adrenalectomy is the cornerstone of treatment for UPA, but outcomes after surgery are variable. The cause of resistant hypertension after surgery is still a matter of debate. Our aim was to investigate cure rates after surgery and to evaluate preoperative factors that might influence the surgical outcome. Between 2000 and 2021, the charts of 71 Tunisian patients who underwent laparoscopic adrenalectomy for UPA were retrospectively reviewed. Preoperative medical records were collected and follow-up data (1-158 months) were registered. Antihypertensive medication doses were calculated using defined daily doses (DDD) and postoperative outcomes were assessed using the Primary Aldosteronism Surgical Outcome (PASO) criterion. Of 91 enrolled patients, 71 (59% women, mean age 46 years, median length of follow-up 21 months) were suitable for evaluation. Thirty-four patients (48%) had complete clinical success according to the PASO criteria. The most relevant factors associated with complete clinical success on univariate analysis were: absence of diabetes (p= 0.007), low body mass index (BMI) (p= 0.001), lower preoperative DDD (p= 0.01), preoperatively controlled blood pressure (p= 0.024), higher plasma aldosterone to renin ratio (ARR) (p= 0.001), adenoma subtyping (p <0.001) and aldosteronoma resolution score (ARS) (p= 0.002). Multivariate regression analysis showed that the major predictors of complete clinical success were absence of diabetes (OR: 5.205), a BMI < 30 (OR: 4.930), a plasma ARR > 332 (OR: 4.554) and an ARS ≥ 3 (OR: 2.056). Complete and partial clinical response rates were achieved in respectively 48 and 43% of cases. The main predictors of complete resolution of hypertension were absence of diabetes, low BMI, high plasma ARR and high ARS. Taking these factors into account may help identify patients at risk of persistent postoperative hypertension who may require long-term surveillance and medication.

Pathologic HDAC1/c-Myc signaling axis is responsible for angiotensinogen transcription and hypertension induced by high-fat diet

High-fat diet (HFD)-induced obesity is a cause of resistant hypertension. We have shown a possible link between histone deacetylases (HDACs) and renal angiotensinogen (Agt) upregulation in the HFD-induced hypertension, whereas the underlying mechanisms remain to be elucidated. Here, using a HDAC1/2 inhibitor romidepsin (FK228) and siRNAs, we determined roles of HDAC1 and HDAC2 in HFD-induced hypertension and found the pathologic signaling axis between HDAC1 and Agt transcription. Treatment with FK228 canceled the increased blood pressure of male C57BL/6 mice induced by HFD. FK228 also blocked upregulation of renal Agt mRNA, protein, angiotensin II (Ang II) or serum Ang II. Activation and nuclear accumulation of both HDAC1 and HDAC2 occurred in the HFD group. The HFD-induced HDAC activation was associated with an increase in deacetylated c-Myc transcription factor. Silencing of HDAC1, HDAC2 or c-Myc in HRPTEpi cells decreased Agt expression. However, only HDAC1 knockdown, but not HDAC2, increased c-Myc acetylation, suggesting selective roles in two enzymes. Chromatin immunoprecipitation assay revealed that HFD induced the binding of HDAC1 and deacetylated c-Myc at the Agt gene promoter. A putative c-Myc binding sequence in the promotor region was necessary for Agt transcription. Inhibition of c-Myc downregulated Agt and Ang II levels in kidney and serum, ameliorating HFD-induced hypertension. Thus, the abnormal HDAC1/2 in the kidney may be responsible for the upregulation of the Agt gene expression and hypertension. The results expose the pathologic HDAC1/c-myc signaling axis in kidney as a promising therapeutic target for obesity-associated resistant hypertension.

PD03-07 PREDICTORS OF SUCCESSFUL OUTCOME AFTER ADRENALECTOMY FOR UNILATERAL PRIMARY ALDOSTERONISM (UPA)

You have accessJournal of UrologyCME1 Apr 2023PD03-07 PREDICTORS OF SUCCESSFUL OUTCOME AFTER ADRENALECTOMY FOR UNILATERAL PRIMARY ALDOSTERONISM (UPA) Ahmed Saadi, Mohamed Ali Bedoui, Selim Zaghbib, Seif Mokaddem, Ibtissem Ben Nacef, Hamza Boussaffa, Haroun Ayed, Amine Derouiche, Karima Khiari, Marouene Chakroun, and Riadh Ben Slama Ahmed SaadiAhmed Saadi More articles by this author , Mohamed Ali BedouiMohamed Ali Bedoui More articles by this author , Selim ZaghbibSelim Zaghbib More articles by this author , Seif MokaddemSeif Mokaddem More articles by this author , Ibtissem Ben NacefIbtissem Ben Nacef More articles by this author , Hamza BoussaffaHamza Boussaffa More articles by this author , Haroun AyedHaroun Ayed More articles by this author , Amine DerouicheAmine Derouiche More articles by this author , Karima KhiariKarima Khiari More articles by this author , Marouene ChakrounMarouene Chakroun More articles by this author , and Riadh Ben SlamaRiadh Ben Slama More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003220.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: UPA is the most common surgically curable form of endocrine hypertension. The underlying cause of resistant hypertension after surgery remains controversial. The aim of this study was to identify preoperative factors predictive of complete clinical success after laparoscopic adrenalectomy for UPA. METHODS: Between 2000 and 2021 patients treated by laparoscopic adrenalectomy for UPA were enrolled in this retrospective study. Preoperative data were divided into 3 categories: clinical, biological and radiological variables and follow up data was recorded. For determining factors influencing surgical outcome patients were divided into 3 groups: 1) complete clinical success (CS): normal blood pressure(BP) (≤140/90 mmHg) without antihypertensive medications (AHM). 2) Partial CS: the same BP as before surgery with less AHM or a reduction in BP with either the same amount or less AHM. 3) Absent CS: unchanged or increased BP with either the same amount or an increase in AHM. We performed an univariate and multivariate regression analysis. Statistical significance was defined as a P value of <0.05. RESULTS: Our study included 71 patients (59% female, mean age 46 years, median follow up 21 months). The mean duration of hypertension before surgery was 82.9±75.9 months. Preoperative mean DDD was 2.8±1.1 with 66% of patients having poorly controlled hypertension. Retroperitoneoscopic adrenalectomy was performed in 47 patients (66%). Four patients (6%) underwent partial adrenalectomy. Only 2 patients required conversion to open adrenalectomy. Complication rate (Clavien-Dindo ≥3a) was 4%. No mortality was registered. After adrenalectomy complete plus partial CS occured in 64 patients (91%).The following factors were associated with a complete clinical success by univariate analysis : absence of diabetes (p=0.007), low BMI (p=0.001), lower levels of preoperative AHM (p=0.01), controlled preoperative BP (p=0.024), higher levels of plasma aldosterone-to-renin ratio (ARR) (p=0.001), adenoma classification (p<0.001) and aldosteronoma resolution score (ARS) (p=0.002). Multivariate regression analysis revealed that the main determinants of complete clinical success were : absence of diabetes (OR: 5.205, 95% CI 1.411-19.206), low BMI (OR: 0.904, 95% CI 0.820-0.997), plasma ARR >332 (OR: 1.003, 95% CI 1.001-1.004) and ARS score ≥3 (OR: 2.056, 95% CI 1.210-3.491). CONCLUSIONS: The majority of our patients (91%) experienced clinical benefit from adrenalectomy.The main determinants of cured hypertension were absence of diabetes, low BMI, high levels of plasma ARR and high ARS score. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e77 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ahmed Saadi More articles by this author Mohamed Ali Bedoui More articles by this author Selim Zaghbib More articles by this author Seif Mokaddem More articles by this author Ibtissem Ben Nacef More articles by this author Hamza Boussaffa More articles by this author Haroun Ayed More articles by this author Amine Derouiche More articles by this author Karima Khiari More articles by this author Marouene Chakroun More articles by this author Riadh Ben Slama More articles by this author Expand All Advertisement PDF downloadLoading ...

Associated factors and hemodynamic characteristics of resistant hypertension in the elderly.

The purpose of this study was to explore the associated factors and hemodynamic characteristics of resistant hypertension (RHTN) in the elderly. A total of 283 patients aged ≥60 years with hypertension were evaluated by the CNAP™ monitor. Among them, 240 patients were non-RHTN (controlled hypertension with use of three or fewer antihypertensive medications) and 43 patients were RHTN (uncontrolled hypertension despite the concurrent use of ≥3 antihypertensive drugs at optimized doses, including a diuretic, or achieving target blood pressure with the use of ≥4 antihypertensive medications). RHTN was associated with higher body mass index (BMI), longer hypertension duration, and coronary heart disease (p=.004, p<.001, and p=.042, respectively). The mean number of antihypertensive medications was greater in patients with RHTN (p<.001). Hemodynamic analysis revealed higher cardiac output in the RHTN group than in the non-RHTN group, while no difference was observed in systemic vascular resistance. Screening for secondary etiology showed that, among the 43 patients with RHTN, 8 (18.6%) had chronic kidney disease, 8 (18.6%) had obstructive sleep apnea, 4 (9.3%) had primary aldosteronism, 2 (4.7%) had renovascular disease. No significant differences were observed in the cardiac output and systemic vascular resistance values between different causes of RHTN. These findings suggest that higher body mass index, longer hypertension duration, and coronary heart disease emerged as the associated factors of RHTN in the elderly. RHTN is characterized by higher cardiac output. Screening for the possible secondary etiology of RHTN in the elderly patients is necessary and important.

PS-C27-3: MEASURING ANTIHYPERTENSIVE DRUG CONCENTRATIONS TO DETERMINE NON-ADHERENCE IN HYPERTENSIVE PATIENTS WITH AND WITHOUT KIDNEY TRANSPLANTATION

Introduction: Non-adherence to antihypertensive drugs (AHDs) is one of the main causes of resistant hypertension which is defined as uncontrolled blood pressure despite the prescription of at least 3 AHDs. Objectives: Our primary objective was to determine the prevalence of non-adherence to AHDs in patients visiting the nephrology and vascular outpatient clinics. Inclusion rates at both departments allowed comparison between non-adherence of kidney transplantation (KT) patients with patients without KT as secondary objective. Design and method: This was a prospective observational study called RHYME-AD (Resistant Hypertension: MEasure Antihypertensive Drugs, MEC-2020–0096). Patients were eligible if they used at least 2 AHDs that could be measured with a validated UPLC-MS/MS method and had an office blood pressure &gt; 140 and/or 90 mmHg. After informed consent was signed, rest material was collected from a regular venipuncture measurement. The total absence of drug in blood (&lt;lower limit of detection) was defined as non-adherent. We made comparisons between patients with and without KT and with and without resistant hypertension, defined as an office blood pressure &gt; 140 and/or 90 mmHg despite the use of 3 or more AHDs. Results: Material was available from 143 patients of which 93 had a KT and 66 patients fulfilled the definition of resistant hypertension. The overall adherence rate was 78.3%. From the non-adherent patients 87.8% was partially non-adherent and 12.2% non-adherent for all prescribed AHDs. When looking at the two separate groups, with and without KT, more patients in the non-KT cohort fulfilled the definition of resistant hypertension as compared to the KT-cohort (62.0% vs 37.6%, p = 0.005). There was a significant difference between having resistant hypertension and being non-adherent (non-adherence RH vs non-RH, 31.8% vs 13.0%, p = 0.023) and having KT and being non-adherent (non-adherence KT vs non-KT, 14.0% vs 36.0%, p = 0.005). In addition, patients with KT and no resistant hypertension were the most adherent to AHDs (91.2%). Conclusions: Hypertensive patients with a KT are less likely to be non-adherent to their AHDs as compared to hypertensive patients without a KT. However, patients fulfilling the definition of having resistant have a higher risk of being non-adherent to AHDs.

JS-NG-7: ASSOCIATION BETWEEN PLASMA ALDOSTERONE CONCENTRATION AND AMBULATORY BLOOD PRESSURE PROFILE IN PATIENTS WITH PRIMARY ALDOSTERONISM

Background: Primary aldosteronism (PA) is a major cause of curable hypertension with its morbidity rate 5–10% in hypertensive patients reported, and thus is highly prevalent in patients with hypertension, a cause of resistant hypertension, and closely associated with target organ damage compared with essential hypertension. Although an altered circadian blood pressure (BP) rhythm estimated by ambulatory blood pressure monitoring (ABPM) has been highlighted as a major contributor of CVD in essential hypertension, there would be very few reports investigating clinical significance of ABPM in PA patients. Therefore, we aimed to examine a possible association between plasma aldosterone concentration (PAC) and ABPM profile in PA patients. Methods: Consecutive 27 PA patients, who had been diagnosed by the functional tests and underwent adrenal venous sampling (AVS) from April 2015 to March 2020, were included in this study. All clinical indexes including 24-hour ABPM were measured during the hospitalization, and all participants received dietary salt restriction with 6 g/day of salt. The 24-hour ABPM was performed from the first day of hospitalization to the next day, and AVS was performed on the third day in the morning. Regarding PAC measurement, we collected blood samples during AVS. After resting for 30 minutes in a supine position, blood samples were collected from inferior vena cava by catheterization. During AVS, we also performed ACTH stimulation, and blood samples were collected essentially 1 hour after the stimulation. Results: We firstly analyzed a correlation between PAC and ABPM profile and found that PAC measured after ACTH stimulation (post-PAC) was negatively correlated with nocturnal dipping rate in both systolic and diastolic BPs (SBP and DBP) (R = -0.430, P = 0.025, and R = -0.431, P = 0.025, respectively), while PAC measured before ACTH stimulation (pre-PAC) was not. Thus, according to the median of post-PAC, we divided participants into lower PAC and higher PAC groups and compared clinical characteristics between the two groups. Compared to the lower PAC group, nocturnal SBP and DBP dipping rates and serum potassium levels were significantly decreased in the higher PAC group (SBP dipping 10.3 ± 6.4 vs 3.5 ± 7.7 %, P = 0.02; DBP dipping 13.6 ± 7.7 vs 5.5 ± 6.3 %, P = 0.01; serum potassium 4.1 ± 0.3 vs 3.7 ± 0.4 mEq/L, P = 0.03). Conclusions: In this cross-sectional study, higher PAC was significantly associated with a non-dipper circadian BP profile characterized by lower nocturnal BP dipping rates in PA patients. Prospective longitudinal study is warranted to seek for a causal relationship between hyperaldosteronism and ABPM profile.

Device-Based Therapy for Resistant Hypertension: An Up-to-Date Review.

Hypertension is the major risk factor for cardiovascular morbidity and mortality. Matter of fact, untreated hypertension can worsen the overall health, whereas pharmacotherapy can play an important role in lowering the risk of high blood pressure in hypertensive patients. However, persistent uncontrolled hypertension remains an unsolved condition characterized by non-adherence to medication and increased sympathetic activity. This paper will review the non-pharmacological treatments for resistant hypertension (RH) that have emerged in recent years. In addition, the technologies developed in device-based RH therapy, as well as the clinical trials that support their use, will be discussed. Indeed, the novel device-based approaches that target RH present a promising therapy which has been supported by several studies and clinical trials, whereas drug non-adherence and high sympathetic activity are known to be the main causes of RH. Nevertheless, some additional aspects of these RH systems need to be tested in the near future, with a particular focus on the device’s design and availability of randomized controlled trials.

Abstract P352: Rates Of Diagnostic Work-up By Magnetic Resonance Imaging Of The Abdomen For Patients With Resistant Hypertension

Resistant hypertension affects 8.9% to 33% of all persons with hypertension, and is associated with higher risks of death, major cardiovascular events, left ventricular hypertrophy, progressive kidney disease, and cognitive impairment. Guidelines recommend diagnostic work-up for resistant hypertension including assessment of the renal vasculature but rates of diagnostic studies in real-world practice are not well known. From a cohort of patients with resistant hypertension (n = 4660) from 2008-2016 prior to the founding of the Stanford Hypertension Center, we quantified assessment of renovascular disease. We observed that 2.5% (n = 118) of the patients had an abdominal magnetic resonance imaging (MR abdomen) performed, and were of ages 45-92, 61% male and 39% female. Although all 118 of these patients had an MR abdomen after their index date of resistant hypertension (their most recent MR abdomen was taken an average of 7.4 years after their index date), only 36% (n = 43) of these 118 patients had imaging reports that described the renal arteries in the body or the conclusion of the report. Of these 43 patients, 7% (n=3) had MR records describing renal artery stenosis. In comparison, 100% (n = 263) of kidney donors who had had an MR abdomen performed during the same interval (2017-2021) had imaging reports that described their renal arteries. Full clinical descriptions of cohorts will be provided. Since abnormalities in renal vasculature can cause hypertension, this lack of renal artery description in imaging reports of patients with resistant hypertension may reveal missed opportunities in multidisciplinary communication and/or in the use of imaging to assess for causes of resistant hypertension. This missed opportunity for diagnosis of renovascular disease is similar to the low screening rates for primary aldosteronism as a cause of resistant hypertension, previously found at Stanford and across the US.

PRIMARY ALDOSTERONISM: INITIAL EXPERIENCE FROM A NEWLY ESTABLISHED ESH HYPERTENSION CENTER OF EXCELLENCE - WORK IN PROGRESS

Objective: Primary aldosteronism is a common, yet underdiagnosed, cause of hypertension and resistant hypertension. It is estimated to be responsible for 6% of all cases of hypertension and 23% of all cases of resistant hypertension and is associated with disproportionately high rates of cardiovascular events and renal damage relative to the degree of hypertension. We sought to determine the prevalence of primary aldosteronism in patients referred to our center with the diagnosis of hypertension or resistant hypertension Design and method: From 08/03/2021 to 04/01/2022, 46 Patients (18 Females, 39.1%) were evaluated for primary aldosteronism. Thirty two patients (69.6%) were diagnosed with hypertension, of which 22 patients were newly diagnosed and were not on antihypertensive therapy. Fourteen patients (30.4%) were diagnosed with resistant hypertension and were on an average of 4 antihypertensive medications (range, 3 to 7). All were screened with Serum aldosterone (Ald) (pg/ml) and Plasma Renin activity (PRA) (mU/L) levels and ratio. To confirm the diagnosis, a seated saline suppression test (SSST) was performed when the Ald/PRA ratio was above 300. Adrenal computed tomography (CT) and adrenal vein sampling (AVS) were recommended or performed whenever the SSST was positive. Results: Of the 32 Patients with hypertension, 7 had an abnormal Ald/PRA ratio, 2 of which had a SSST which was positive in 1. Of the 14 patients with resistant hypertension, 7 (50%) had an abnormal Ald/PRA ratio, 4 of which underwent a SSST which was positive in all 4. Adrenal CT and AVS were done in 3 patients with resistant hypertension and positive SSST. AVS confirmed unilaterality in 2, both with adrenal adenomas. Adrenalectomy was recommended for the 2 patients and was performed in one with significant improvement in blood pressure control. Conclusions: Although this is a small number of evaluated patients, the data suggests that primary aldosteronism is not rare in hypertensive patients and is a common cause of resistant hypertension. All efforts should be made to improve physicians and patients’ awareness about its prevalence.

Abstract #1161422: A Blessing in Disguise: A rare but major complication of Adrenal vein sampling

Primary hyperaldosteronism(PA), caused by adrenal adenoma or adrenal hyperplasia₁, is a common cause of resistant Hypertension (HTN)₂. Adrenal vein sampling (AVS) helps in differentiating between these two conditions, as treatment will vary. This case highlights a rare complication of AVS.

Evaluation of the Causes of Resistant Hypertension in Non-dialysis Chronic Kidney Disease Patients

Background: In Chronic Kidney disease (CKD), resistant hypertension (RH) is a common condition due to a combination of factors including sodium retention, increased activity of the renin-angiotensin system, and enhanced activity of the sympathetic nervous system. The aim of the study was to determine the causes of resistant hypertension in non-dialysis Chronic Kidney Disease Patients. Methods: This descriptive cross-sectional study was conducted in the department of Nephrology &amp; Internal Medicine of Dhaka Medical College Hospital from 18th January 2016 to 20th may 2016. Patients aged above 18 years admitted with resistant RH and CKD were enrolled in the study after fulfilling the inclusion and exclusion criteria. The study involved 50 CKD patients who had RH. Purposive consecutive type of sampling technique was applied for sample collection. Detail socio-demographic data were collected and recorded in a predesigned questionnaire. Clinical examination and relevant investigations were done. Data was analysed with SPSS version 22.0. P value of &lt;0.05 was considered significant. Result: Maximum number of patients 23(46.0%) were between 46-60 years age group, mean age of the patient was 53.17 ± 8.42 years. Male: female ratio was 1.63:1. Study showed that frequency of RH and CKD gradually increased with age. In case of both sexes, 46-60 years age group showed the highest incidence for CKD. The mean systolic and diastolic blood pressures (BP) were 133.04 ± 12.91 mmHg and 81.07 ± 6.41 mmHg respectively. Those with diabetes mellitus, obesity (BMI &gt; 27.5 kg/m2) and those who were older than 55 years were significantly higher in the RHT group than in the non-RHT group. Conclusion: RH in CKD patients was significantly associated with the presence of obesity, diabetes mellitus and increased age. These factors should always be kept in mind while treating HTN in CKD patients. Bangladesh Crit Care J March 2022; 10 (1): 19-25

Juxtaglomerular cell tumour of the kidney: a rare cause of resistant hypertension.

SummaryJuxtaglomerular cell tumour (JGCT) is an unusually encountered clinical entity. A 33-year-old man with severe long-standing hypertension and hypokalaemia is described. The patient also suffered from polyuria, polydipsia, nocturia and severe headaches. On admission, laboratory investigation revealed hypokalaemia, kaliuresis, high aldosterone and renin levels, and the abdomen CT identified a mass of 4 cm at the right kidney. Kidney function was normal. Following nephrectomy, the histological investigation revealed the presence of a JGCT. Immunostaining was positive for CD34 as well as for smooth muscle actin and vimentin. Following surgery, a marked control of his hypertension with calcium channel blockers and normalization of the serum potassium, renin or aldosterone levels were reached. According to our findings, JGCT could be included in the differential diagnosis of secondary hypertension as it consists of a curable cause. The association of JGCT with hypertension and hypokalaemia focusing on the clinical presentation, diagnostic evaluation and management is herein discussed and a brief review of the existing literature is provided.Learning pointsJuxtaglomerular cell tumours (JGCT), despite their rarity, should be included in the differential diagnosis of secondary hypertension as they consist of a curable cause of hypertension.JGCT could be presented with resistant hypertension along with hypokalaemia, kaliuresis and metabolic alkalosis. Early recognition and management can help to prevent cardiovascular complications.Imaging (enhanced CT scans) may be considered as the primary diagnostic tool for the detection of renal or JGCT.For the confirmation of the diagnosis, a histopathologic examination is needed.

Annals for Educators - December 2021.

Annals for Educators - December 2021.

Understanding resistant hypertension.

Resistant hypertension affects about 17% of the US population. However, it is difficult to diagnose because of multiple factors that influence adequate treatment of BP, including patient lifestyle and comorbidities, improper therapeutic regimens, and secondary mechanisms. Possible causes of resistant hypertension include nonmodulator hypertension, which affects patients who have an inappropriate response to elevated sodium through the renin-angiotensin-aldosterone system. Early identification and frequent follow-up can help patients achieve BP goals more rapidly and may reduce morbidity and mortality associated with complications of hypertension, including cerebrovascular accident, cardiovascular disease, and kidney disease.

Abstract 16932: Primary Hyperaldosteronism And Resistant Hypertension In Pregnancy

Case Presentation: A 42-year-old woman with history of primary hyperaldosteronism (PA), IDDM and chronic kidney disease stage 3b (baseline Cr 2.5 mg/dl) presented at 10 weeks gestation with uncontrolled hypertension during pregnancy. Given prior difficulties conceiving and lack of discussions surrounding pregnancy risks, preconception counseling had not been done. She was taking carvedilol, spironolactone, and furosemide at pregnancy diagnosis. Given unclear safety profile in pregnancy, her spironolactone was discontinued. Her regimen was uptitrated to nifedipine 90 mmHg, carvedilol 50mg BID, hydralazine 50mg TID and furosemide 80mg BID. At 18 weeks gestation, she was readmitted with severe range hypertension and fluid overload unresponsive to escalating diuretic dosing. Due to poor urine output and creatinine to 5.5 mg/dl, she was initiated on dialysis. Her fetus was diagnosed with severe intrauterine growth restriction (IUGR) and umbilical doppler noted reversal of umbilical artery end-diastolic flow indicating severely elevated arterial resistance (Figure). During admission, she developed resistant hypertension requiring nicardipine and esmolol drips and severe headache, concerning for superimposed preeclampsia (SIPE). At 25 weeks gestation, she was taken for urgent c-section. Given extreme prematurity and growth restriction, her newborn baby passed away shortly after delivery. Discussion: This case highlights complications which arise from PA and antepartum persistent hypertension including progression of kidney disease, heart failure, IUGR, SIPE, and preterm delivery. It further highlights unique challenges using targeted therapies of mineralocorticoid receptor antagonists in PA in pregnancy. This information is crucial as PA is an increasingly recognized cause of resistant hypertension in young adults. Both PA and preeclampsia involve pathophysiologic mechanisms in the RAAS pathway and deserve further attention and research.

The efficiency of dapagliflozin as add-on therapy in obese patients with resistant hypertension and chronic kidney disease

Abstract Background Obesity, insulin resistance, renal dysfunction, hyperuricemia are some of the most common causes of resistant hypertension (RH). A close relationship exists between RH and fluid retention. Currently, there is no consensus regarding pathogenetic therapy of RH and there are no studies on the effects of sodium–glucose cotransporter-2 (SGLT2) inhibitors in obese patients with RH and chronic kidney disease (CKD). The aim was to evaluate the effects of dapagliflozin (D) in obese P with RH and CKD stages 3a. Methods 45 obese P (mean body mass index (BMI) 34.2 kg/m2, waist circumference (WC) 104 cm) with true RH and CKD 3a (eGFR 45–59 mL/min/1.73m2) were included in the study under conventional therapy full doses of appropriate combinations (mean 3.7 antihypertensive drugs). The D at daily doses of 10 mg was added to previous treatment. The blood pressure (BP) was measured in the office and by ambulatory BP monitoring. Anthropometry, metabolic profile, including oral glucose tolerance test with insulin, homeostatic model assessment HOMA-R, hematocrit (Hct), uric acid, potassium (K), serum creatinine, calculated GFR were performed at baseline and after 12 weeks treatment. Results At baseline were excellent correlations between BMI and SBP (r=0.45, P&amp;lt;0.01), eGFR and DBP (r=−0.33, P&amp;lt;0.05), eGFR and Hct (r=0.31, P&amp;lt;0.05), BMI and HOMA-R (r=0.34, P&amp;lt;0.05). At baseline mean HOMA-R was 2,8±0.7, eGFR 53.50±3.26 ml/min/1.73 m2, uric acid 469±23 nmol/L, K 4,9±0.9 mmol/L. The asymptomatic hyperuricemia was observed in 57%, impaired glucose tolerance in the 37%. After 12 weeks administration of D, the mean 24 h ambulatory BP effectively decreased (−7.6/−4.3 mmHg; P&amp;lt;0.05 for both; respectively. Also, there were significant decreases in BMI (−2,1 kg/m2, P&amp;lt;0.01), WC (−4,8 cm, P&amp;lt;0.01), fasting glucose (−0,8 mmol/L, P&amp;lt;0.01) and uric acid (−42 nmol/L, P&amp;lt;0.01) without changes in insulin secretion and not significant improvement in HOMA-R (2,8±0.7 versus 2.4±0.4). Mean eGFR and K on D remained unchanged, however, the albumin/creatinine ratio decreased significantly (P&amp;lt;0.05). Also, the Hct significantly increased after start of D (P&amp;lt;0.01). By linear regression analysis, the independent associated factor for the change SBP was baseline BMI (P&amp;lt;0.05) and for the change DBP baseline eGFR (P&amp;lt;0.05). Conclusion Dapagliflozin shows an additional antihypertensive effect when added to the prior combination therapy in obese patients with RH and CKD 3a without risk of hyperkalemia. Dapagliflozin increase hematocrit, possibly due to its diuretic effects and hemoconcentration. So, positive antihypertensive effect D is due to natriuretic effect and decrease fluid retention. Furthermore, there is also a strong indication that the BP effect is also influenced by weight loss and dapagliflozin administration decreased body mass index, waist circumference, fasting glucose and uric acid, with a tendency to decrease the insulin resistance without changes in insulin secretion. Funding Acknowledgement Type of funding sources: None.

Primary Hyperaldosteronism From Adrenocortical Adenoma Presenting as Seizures and Stroke

Background: Primary hyperaldosteronism, which is unregulated secretion of aldosterone from the adrenal gland, is a common cause of resistant hypertension. Hyperaldosteronism can lead to life threatening cardiovascular and neurological complications emphasizing the crucial need for timely identification and management. We present a case of a young patient who suffered complications as a result of primary hyperaldosteronism. Clinical Case: A 35 year old female with a past medical history of resistant hypertension on four anti-hypertensive medications, primary hyperaldosteronism with known adenoma, CKD stage III, and hyperlipidemia presented to the hospital due to multiple seizures. She was found to be encephalopathic and required intubation for respiratory failure. Her systolic blood pressure was elevated to 250 mmhg. CT scan of the head showed a small left temporal hemorrhage and an MRI brain was revealing of bilateral thalamic infarcts. No neurosurgical intervention, antiplatelet or anticoagulation was recommended. She was admitted to the ICU and started on nitroprusside infusion. CT scan of the abdomen showed a 17 mm right adrenal nodule unchanged from prior imaging. Due to concern for pheochromocytoma, she was started on alpha blockade and subsequently beta blockade therapy. After stabilization of patient’s blood pressure, extubation, and improvement in mental status, she was discharged on new anti-hypertensive medications including spironolactone given her hypokalemia. Further endocrine evaluation was pursued. Work up included urine and plasma catecholamines which were not indicative of pheochromocytoma. Morning cortisol level was within normal limits. Plasma aldosterone level was 30, plasma renin was 0.90 with an aldosterone/renin ratio of 33 suggestive of primary hyperaldosteronism. Though the patient had known primary hyperaldosteronism with an adenoma, she had poor follow up and did not comply with initial recommendation of surgical removal of adenoma prior to her stroke. After medical stabilization following her stroke, a laparoscopic right adrenalectomy was performed. Pathology showed an adrenal cortical adenoma with no evidence of pheochromocytoma. Post-surgical systolic blood pressures were less than 120 mmhg. She was able to come off of spironolactone with plans to gradually discontinue other antihypertensive medications. Conclusion: This case emphasizes the importance of testing for primary hyperaldosteronism particularly in young patients with resistant hypertension. Furthermore, primary hyperaldosteronism should be considered as an underlying etiology for young patients who suffer from strokes particularly in the setting of hypertension. Given the reversibility of primary aldosteronism from an adrenocortical adenoma with surgery, life threatening complications such as cerebrovascular accidents can be prevented.