Long-standing Hypertension Research Articles

Case Report: Endovascular approach with kissing stent technique in aortoiliac occlusive disease (Leriche syndrome) patient

Background Aortoiliac occlusive disease (AIOD) or Leriche syndrome, is a form of peripheral arterial disease involving the infrarenal aorta and iliac arteries. The presentation of AIOD ranges from asymptomatic cases to limb-threatening emergencies. Advances and innovations in endovascular devices have replaced traditional surgical interventions for the management of AIOD. Here we report a case of a 52-year-old man presenting with AIOD managed by endovascular approach using kissing stent technique. Case presentation A 52-year-old man, with history of chronic coronary artery disease, diabetes mellitus type 2, long-standing hypertension, and a significant history of smoking, was admitted to our hospital with symptoms of long-standing bilateral claudication which recently progressed to rest pain. A history of AIOD was previously established. AIOD (TASC II Type D) diagnosis was made by lower extremity duplex ultrasound and CT angiography. The patient underwent urgent percutaneous transluminal angioplasty with kissing stent technique. The patient was discharged 4 days after the procedure without any significant complaints, received best medical therapy. Conclusion Endovascular interventions present excellent alternatives to surgical techniques in the treatment of complex AIOD. Herein we presented an endovascular treatment of AIOD utilizing the kissing stent technique which showed satisfactory outcomes.

Acute exacerbation of congestive heart failure following intranasal cocaine use

Background: Most presentations of decompensated congestive heart failure occur in patients diagnosed with pre-existing heart failure. Decompensation presents as progressive dyspnea, abdominal and peripheral congestions, as well as neurological symptoms. It typically occurs following physiological stressors such as infection, arrhythmia, or medical non-adherence. Chronic heart failure may result from cardiovascular comorbid conditions, such as coronary artery disease, valvular disease, and long-standing hypertension. Long term cocaine use also results in adverse cardiovascular health. Cocaine use can augment pre-existing risk factors for both chronic congestive heart failure and acute decompensations - namely, coronary artery disease, congestive heart failure, and peripheral vascular disease. It can also independently pose a cardiovascular risk by causing acute ischemia, vasoconstriction, tachycardia, systolic dysfunction, and cardiac remodeling. The Case: the case of a 49-year-old Caucasian male, who presented with worsening dyspnea on exertion and bilateral peripheral edema extending to his abdomen. His symptoms worsened over the preceding week and began after three consecutive days of intranasal cocaine use. He presented with a background history of congestive heart failure, coronary artery disease, peripheral vascular disease, a 30 pack-year smoking history, and weekly cocaine use for the past 12 years. Conclusion: Cocaine use can lead to decompensation of congestive heart failure in patients with extensive cardiac and vascular disease. Cocaine use can also acutely worsen systolic function and cause demand ischemia, on a background of chronic remodelling and atherosclerotic changes. Patient Consent Obtained: Yes

7652 Functional Adrenocortical Carcinoma Presenting As Uncontrolled Hypertension

Abstract Disclosure: B.R. Bedell: None. M. Fariduddin: None. J. Sanchez Perez: None. S.C. Kukreja: None. R.M. Sargis: None. Adrenocortical carcinoma is a rare malignancy, with approximately 2,000 cases reported in the United States since 1970.[1] Many secrete excess adrenocortical hormones, adding to morbidity and mortality. Surgery can be curative or prolong survival if diagnosis is made early, but prognosis remains poor due to delayed detection.[2] We present a case of metastatic functional adrenocortical carcinoma that presented with consequences of long-standing uncontrolled hypertension. A 59-year-old male with history of hypertension and CAD presented to the hospital with worsening bilateral pitting edema, dyspnea on exertion, palpitations, headaches, and proximal muscle weakness over for multiple months. His hypertension (HTN) was noted to be uncontrolled despite use of multiple antihypertensives (daily Lasix 20 mg, Lisinopril 40 mg, Metoprolol Succinate 100 mg and Amlodipine 10 mg). Hypokalemia of 3.0 mmol/l (3.5 - 5.2 mmol/l) was noted. Echocardiogram revealed new heart failure with preserved ejection fraction. A subsequent nuclear stress test incidentally revealed a right-sided 15 cm retroperitoneal mass, invading the IVC and the right hepatic lobe. An AM dexamethasone suppression test was notable for a cortisol of 39 ug/dl (<1.8 ug/dl) and an undetectable ACTH level of <1.5 pg/ml (7.2 - 63.3 pg/mL), suggestive of primary hypercortisolism. 24-hour urine cortisol was 930.6 ug/d, (<=60.0 ug/d), DHEA-s 1105 ug/dL (52 - 295 ug/dL), Androstenedione 2.641ng/mL (0.230 - 0.890 ng/mL), and 17-Hydroxyprogesterone 299.87 ng/dL (<=138.00 ng/dL). Plasma metanephrines were normal and aldosterone levels were undetectable, confirming cortisol and its precursor excess as the cause of hypertension. Biopsy of the mass was consistent with adrenocortical carcinoma. Due to disease extent, the patient was not a candidate for surgical debulking, and radiation therapy was commenced. Ketoconazole 200 mg and Spironolactone 150 mg twice daily led to improvement in HTN and hypokalemia. His course was further complicated by bacteremia and acute pulmonary embolism. The patient eventually elected to pursue hospice care. Adrenocortical carcinoma remains challenging to detect at early stages given a paucity of symptoms. This case highlights the need to have a high index of suspicion for hypercortisolism in patients with uncontrolled HTN and hypokalemia, as this may be indicative of a functional adrenal cancer. This could be a potential strategy for earlier diagnosis, thereby increasing survival rates by improving disease amenability to surgical intervention. (1.) Sharma E, Dahal S, Sharma P, et al. The Characteristics and Trends in Adrenocortical Carcinoma: A United States Population Based Study. J Clin Med Res. 2018;10(8):636-640. doi:10.14740/jocmr3503w (2.) Vaidya A, Nehs M, Kilbridge K. Treatment of Adrenocortical Carcinoma. Surg Pathol Clin. 2019;12(4):997-1006. doi:10.1016/j.path.2019.08.010 Presentation: 6/2/2024

5142 Pheochromocytoma In The ICU- Hiding In Plain Sight

Abstract Disclosure: N. Chandrashekar: None. B. Arafah: None. Introduction: Pheochromocytomas are catecholamine-secreting tumors that are rare but dangerous and occur in <0.2% of patients with hypertension. Case: A 28 year old female with a 10 year history of hypertension and invasive stage 2b cervical cancer s/p chemoradiation presented to the hospital with circulatory shock from Takutsubo cardiomyopathy requiring intubation, vasopressors, CVVH, and ECMO. The endocrinology service was consulted due to a highly vascular, 3.6 cm, ∼23 Hounsfield units right adrenal mass evidenced on CT abdomen done months prior to admission. There were elevations in plasma normetanephrine to 15 nmol/L (ref <0.90 nmol/L), plasma metanephrine to 1.5 nmol/L (ref <0.50 nmol/L), urinary metanephrine to 565 ug/24-hours (ref 36 - 209 ug/24-hr), and urinary normetanephrine to 2580 ug/24-hr (ref 95 - 449 ug/24-hr). With her acute illness and recent use of vasopressors and quetiapine, these labs could not be accurately interpreted, and outpatient follow up was recommended. She was discharged home on metoprolol and hydralazine for hypertension management by her primary team. She was re-admitted to the CICU 2 days later for hypertensive emergency with flash pulmonary edema. With further questioning, she endorsed longstanding hypertension with episodes of headaches, palpitations, and vomiting. Her cancer therapy related menopause caused frequent nighttime hot flashes while inpatient. These episodes precipitated witnessed symptoms of catecholamine release with severe hypertension and palpitations. It was noted during her hospitalization that her symptoms were controlled during the day with frequent escape during the night despite continuous alpha and subsequent beta blockade every 6 hrs. Estrogen therapy would have been beneficial, however given a recent DVT, this was avoided and instead megestrol acetate and venlafaxine were used. With these additions, her adrenergic spells completely resolved. She then underwent a right adrenalectomy and had no significant fluctuations in her BP intraoperatively with complete resolutions of symptoms postoperatively. The pathology revealed a right 2.7 cm pheochromocytoma with no local invasion or distant metastasis. Conclusion: This is a case of pheochromocytoma crisis with cardiogenic shock followed by subsequent hypertensive emergency in the setting of inappropriate beta-blocker use. Confounders like vasopressors (increases catecholamines), intrinsic stress of critical illness (increases catecholamines), and quetiapine use (can increase normetanephrine levels) make it difficult to analyze labs. In these cases, a thorough history and imaging are key to establishing a diagnosis and initiating life-saving treatment. Another unique feature of this case is the control of the patient’s triggering menopausal hot flashes with megace and venlafaxine to preempt adrenergic spells during her admission. Presentation: 6/2/2024

Epigenetic Alteration of Smooth Muscle Cells Regulates Endothelin-Dependent Blood Pressure and Hypertensive Arterial Remodeling.

Long-standing hypertension (HTN) affects multiple organ systems and leads to pathologic arterial remodeling, which is driven largely by smooth muscle cell (SMC) plasticity. Although genome wide association studies (GWAS) have identified numerous variants associated with changes in blood pressure in humans, only a small percentage of these variants actually cause HTN. In order to identify relevant genes important in SMC function in HTN, we screened three separate human GWAS and Mendelian randomization studies to identify SNPs located within non-coding gene regions, focusing on genes encoding epigenetic enzymes, as these have been recently identified to control SMC fate in cardiovascular disease. We identified SNPs rs62059712 and rs74480102 in the promoter of the human JMJD3 gene and show that the minor C allele increases JMJD3 transcription in SMCs via increased SP1 binding to the JMJD3 promoter. Using our novel SMC-specific Jmjd3-deficient murine model ( Jmjd3 flox/flox Myh11 CreERT ), we show that loss of Jmjd3 in SMCs results in HTN, mechanistically, due to decreased EDNRB expression and a compensatory increase in EDNRA expression. As a translational corollary, through single cell RNA-sequencing (scRNA-seq) of human arteries, we found strong correlation between JMJD3 and EDNRB expression in SMCs. Further, we identified that JMJD3 is required for SMC-specific gene expression, and loss of JMJD3 in SMCs in the setting of HTN results in increased arterial remodeling by promoting the SMC synthetic phenotype. Our findings link a HTN-associated human DNA variant with regulation of SMC plasticity, revealing therapeutic targets that may be used in the screening and/or personalized treatment of HTN.

Case Report: Endovascular approach with kissing stent technique in aortoiliac occlusive disease (Leriche syndrome) patient

Background: Aortoiliac occlusive disease (AIOD) or Leriche syndrome, is a peripheral artery disease, specifically affecting the infrarenal aorta and iliac arteries. Presentation of AIOD patients ranged from asymptomatic to having limb-threatening emergencies. Advances and innovations in endovascular devices have replaced surgical approach for AIOD treatment. Here we reported a 52-year-old man presenting with AIOD managed by endovascular approach using kissing stent technique. Case presentation: A 52-year-old man, with history of chronic coronary artery disease, diabetes mellitus type 2, long-standing hypertension, and who was a heavy smoker, was admitted to our hospital with symptoms of long time with bilateral claudication and became leg rest pain. He had history of aorto-infrarenal occlusion known from previous percutaneous coronary intervention from right and left femoral artery access. Aortoiliac occlusive disease (TASC II Type D Class) diagnosis was made by lower extremity duplex ultrasound and CT angiography. The patient underwent urgent percutaneous transluminal angioplasty with kissing stent technique. The patient was discharged 4 days after the procedure without any significant complaints, received optimal medical treatment, and was educated about smoking cessation. Conclusion: Treatment of AIOD should include both modification of risk factors and efforts to increase perfusion to the lower extremities. An endovascular approach is an excellent alternative and may replace surgical approach in complex aortoiliac obstructive disease. In this case report, an endovascular approach with kissing stent technique showed good results for the patient.

Prevention and treatment of hypertensive left ventricular hypertrophy.

Left ventricular (LV) hypertrophy (LVH) is a well recognized target organ adaptation to longstanding uncontrolled hypertension and other cardiovascular risk factors. It is also a strong and independent predictor of many cardiovascular disorders. This focused review explores the current concepts in screening, diagnosis, prevention, and treatment of LVH in patients with hypertension. Currently, the primary screening and diagnostic tools for LVH are ECG and 2D echocardiography. Implementing machine learning in the diagnostic modalities can improve sensitivity in the detection of LVH. Lifestyle modifications, blood pressure control with antihypertensive therapy, and management of comorbidities aid in preventing and reversing LV remodeling. LVH is a common and often silent complication of hypertension. Prevention and reversal of LV remodeling are crucial for cardiovascular risk reduction in patients with hypertension.

Hepatopulmonary syndrome- a case report

Patients with long-standing pulmonary hypertension and liver disease are prone to the development of hepatopulmonary syndrome. Several diagnostic modalities and treatments have been researched for its management. In this paper, we will discuss the approach to a patient with HPS based on a patient admitted to our facility.

Ocular disorders among stroke patients in Federal Teaching Hospital, Lokoja, Nigeria

Objectives: To determine the pattern of ocular disorders among stroke patients in Federal Teaching Hospital, Lokoja (FTHL).
 Materials and Methods: Consecutive new stroke patients seen at the Federal Teaching Hospital, Lokoja over a 3-month period were studied. Data was collected with the use of a structured questionnaire divided into four major sections: bio-data, visual history, results of ocular assessment and NEI VFQ-25 quality of life questionnaire. Data analysis was done using SPSS for Windows, version 23.0. Univariate analyses were presented in the form of frequencies, percentages, means, ranges, and standard deviations, charts and tables.
 Results: Eighty-three patients were recruited with an age range of 40-71 years, a mean age of 55.3(±7.1) years. Thirty-nine patients (47.0%) were between the ages of 51 and 60 years. Thirty-four (41.0%) patients were females while 49(59.0%) were males. Of 46 (55.4%) patients that had neuro-imaging, stroke was ischaemic in 37(80.4%) and haemorrhagic in 9(19.6%). Of the 63 patients with left sided stroke, 2 (2.4%), 4(4.8%) and 57(68.7%) had severe, moderate and mild and normal visual impairment respectively while of the 20 patients with right sided stroke, 3(3.6%) each had severe and moderate visual impairment and 14(16.9%) had normal or mild visual impairment. Other ocular abnormalities included corneal anaesthesia and macular hole in 2(1.2%).
 Conclusion: Anterior and posterior segments, together with neuro-ophthalmic disorders were found among stroke patients in this study. Many of the ocular abnormalities are as a result of long-standing uncontrolled hypertension which caused the stroke. It is recommended that awareness should be created among the populace about uncontrolled hypertension. It is also advised that internists should refer hypertensive patients for routine ophthalmic screening.

ICPET Calculator: A Web-Based Application to Standardize the Calculation of Alpha Distensibility in Patients With Pulmonary Arterial Hypertension.

Background Pulmonary vascular distensibility associates with right ventricular function and clinical outcomes in patients with unexplained dyspnea and pulmonary hypertension. Alpha distensibility coefficient is determined from a nonlinear fit to multipoint pressure-flow plots. Study aims were to (1) create and test a user-friendly tool to standardize analysis of exercise hemodynamics including distensibility, and (2) investigate changes in distensibility following treatment in patients with pulmonary arterial hypertension. Methods and Results Participants with an exercise right heart catherization were retrospectively identified from the University of Arizona Pulmonary Hypertension (UA PH) registry and split into a pulmonary arterial hypertension group, a comparator group, and a control group. Right ventricular function was quantified using the coupling ratio and diastolic stiffness. Prototypes of the invasive cardiopulmonary exercise testing (iCPET) calculator were developed using Matlab, Python, and RShiny to analyze exercise hemodynamics and alpha distensibility coefficient, α (%/mm Hg) from multipoint pressure flow plots. Interclass correlation coefficients were calculated for interplatform and interobserver variability in alpha. No significant bias in the intraplatform (Matlab versus RShiny; intraclass correlation coefficient: 0.996) or interobserver (intraclass correlation coefficient: 0.982) comparison of alpha values. Afterload significantly decreased (P<0.05) with no change in alpha distensibility in the pulmonary arterial hypertension group at follow-up. The comparator group had no change in pressure, resistance or alpha distensibility. There were no significant changes in RV diastolic stiffness at follow-up. Conclusions The interactive user interface in the iCPET calculator allows exploration of alpha distensibility using standardized methods. No significant change in alpha distensibility at follow-up suggests that alpha may be less modifiable in patients with long-standing pulmonary arterial hypertension.

THU375 A Case Of Right Eye VI Nerve Palsy In A Patient With Uncontrolled Type 2 Diabetes Mellitus

Abstract Disclosure: C. Musurakis: None. A. Havrylyan: None. J.L. Gilden: None. Background: Uncontrolled type 2 diabetes is one of the most common etiologies of acquired VI nerve palsy. Clinical Case: A 40-year-old Mexican female with uncontrolled type 2 diabetes mellitus (DM), diabetic retinopathy and hypertension was admitted to the hospital due to the new onset of diplopia, headache, and right eye pain. Her symptoms started 2 weeks before seeking medical care and had worsened when she looked towards the right. Duration of DM was more than 10 years, with long-standing history of diet and medication non-compliance. She had never taken the prescribed metformin and insulin, nor did she monitor her blood glucose levels at home. Four years previously, she had received laser therapy to both eyes for diabetic retinopathy. Although she denied numbness or tingling of her extremities, she had a left 4th toe amputation in the past, due to infection, which was complicated by chronic osteomyelitis. There was no prior history of cerebrovascular or cardiac disease. Family history was positive for type 2 DM in both parents. Upon hospital admission, HbA1c was 13.2% (n&amp;lt;5.7). BMI 23.7. Vitals: BP 184/104, HR 110. Labs: blood glucose was 439 mg/dL (n=70-99), CO2 23 mEq/L (n=21-31), AG 12 mmol/L (n=4-11), Beta-Hydroxybutyrate/Acetate 2.0 mmol/L (n=0.1-0.3), venous pH 7.36 (n=7.35-7.45). Physical exam: no conjunctival redness, discharge or swelling around the eye, but inability to abduct the right eye laterally. CT head wo contrast: significant atherosclerotic calcifications within the intracranial segment of right vertebral artery and no acute intracranial abnormality. CTA brain w/wo contrast: no obvious mass effect on 6th cranial nerve territories. MRI of brain and orbit w/wo contrast showed no macroscopic anatomic abnormality or impingement on right abducens nerve but showed minimal white matter changes on the centrum bilaterally. She was diagnosed with an isolated VI facial nerve palsy in the setting of longstanding uncontrolled diabetes mellitus and hypertension. She was started with basal-bolus insulin and antihypertensive therapies and recommended to continue this medication regimen after discharge. She was also advised that gradual recovery of vision may be achieved with glycemic control of DM and hypertension. Conclusion: Although the etiology of acquired VI nerve palsy may be idiopathic, or result from hypertension, trauma, multiple sclerosis, neoplasm, CVA, postsurgical complication, or aneurysm, it is also caused by uncontrolled diabetes mellitus combined with hypertension. It is to be noted that when neoplasm or aneurysm is the cause, the history and examination often reveals the presence of other neurologic symptoms or signs. Reference: Patel SV, Holmes JM, Hodge DO, Burke JP. Diabetes and hypertension in isolated sixth nerve palsy: a population-based study. Ophthalmology. 2005 May;112(5):760-3. doi: 10.1016/j.ophtha.2004.11.057. PMID: 15878054. Presentation: Thursday, June 15, 2023

FRI601 Unique Considerations For Workup And Management Of An 11 Year Old Male With Concern For A Neuroendocrine Tumor

Abstract Disclosure: N.C. Gunaratne: None. D. Deplewski: None. Background: Pheochromocytoma/paragangliomas are very rare in children. In patients who are undergoing work up for paragangliomas and pheochromocytomas, special considerations need to be made to distinguish neuroendocrine tumor findings from medication and other symptoms. Clinical Case: An 11 yo male with past medical history of migraines presented with new onset seizure, hypertension and tachycardia. Initial exam was remarkable for severe lower back pain, which eventually progressed to generalized pain. His tachycardia and hypertension were initially thought to be related to his pain, but were not improved with escalating pain and intermittent anti-hypertensive medications – leading to admission to the intensive care unit. He was started on lisinopril and metoprolol, but continued to have persistent tachycardia and hypertension.Initial work up included an echocardiogram revealing concentric left ventricular hypertrophy suggesting long-standing hypertension, MRI brain significant for Posterior Reversible Encephalopathy Syndrome, MRI abdomen and spine with no significant findings, and elevated urine metanephrines. Urine and serum catecholamines and serum metanephrines were also elevated, but not at levels typical of neuroendocrine tumors. Due to concern for possible pheochromocytoma/paraganglioma, patient was started on alpha-blocker phenoxybenzamine, and had marked improvement in hypertension. Patient was also started on scheduled gabapentin one day after initiation of phenoxybenzamine and noted to have some improvement in pain – making cause of acute improvement in blood pressure less clear. Patient underwent Ga-68 DOTATATE imaging that was significant for “mild to moderately increased activity within the left adrenal gland,” but no distinct lesion was appreciated on scan. After discussion with endocrine surgery, plan was made to monitor the patient in outpatient setting with serial plasma free metanephrines and chromogranin A while continuing phenoxybenzamine. Conclusion: Pheochromocytoma/paragangliomas are very rare in children. In patients who are undergoing work up for paragangliomas and pheochromocytomas, special considerations need to be made when patient has concomitant pain or is on beta-blockers. Ability to interpret urine/plasma metanephrines and catecholamine levels while on beta-blockers and other pharmacologic agents is difficult due to known iatrogenic alterations of these levels. Management for patients with elevated metanephrines without a localized neuroendocrine tumor can consist of pharmacologic intervention with alpha-blockers and close monitoring with serial labs. Presentation: Friday, June 16, 2023

Abstract P374: Greater Burden Of Chronic Kidney Disease Is Associated With Hypertension Prevalence And Management In South Africa

Introduction: Complications e.g., chronic kidney disease (CKD) are frequent with longstanding hypertension, particularly if poorly managed. Hypothesis: We assessed the hypothesis that prevalence and associations of CKD differed by hypertension prevalence, awareness, treatment and control in South Africa using five CKD estimates. Methods: In this randomly selected cross-sectional study, glomerular filtration rate (GFR) was estimated by CKD Epidemiology Collaboration (CKD-EPI) equations [CKD-EPI creatinine (CKD-EPIcr), CKD-EPI cystatin C, CKD-EPI creatinine-cystatin C], Modification of Diet in Renal Disease (MDRD) and Cockcroft-Gault formula (CGF). Blood pressures were measured, and history of hypertension management collected. Results: Among 1092 participants, mean age 43.5 years, 64% women, the prevalence of hypertension was 42% with similar rates in men (41%) and women (43%). In participants with hypertension (n=460), awareness, treatment and control were 61.5% (283/460), 47.2% (217/460) and 27.0% (124/460), with better rates in women compared with men (p&lt;0.001). CKD prevalence (GFR&lt;60 mL/min/1.73m 2 ) was 2.0-5.9% overall using 5 formulae, and significantly higher in participants with (3.9-10.2%) compared to without hypertension (0.6-2.7%) (p&lt;0.001). In participants with hypertension, CKD was higher in those aware (5.7-13.8%) vs unaware (1.1-4.5%) of their diagnosis (p≤0.015), on treatment (6.9-14.3%) vs none (1.2-6.6%) (p≤0.016), and those with controlled (BP&lt;140/90 mmHg) vs uncontrolled hypertension (6.5-15.1% vs. 3-8%, p≤0.096). In models adjusted for age, sex and obesity, higher hypertension prevalence and awareness were significantly (p&lt;0.05) associated with CKD by CKD-EPIcr and MDRD equations; hypertension treatment was significantly associated with CKD by CKD-EPIcr, MDRD and CGF formulae, while hypertension control was not associated with CKD. Conclusions: This study highlights the higher prevalence and greater likelihood of CKD in participants with hypertension and those who were diagnosed and receiving treatment, likely due to the longer duration of their hypertension compared with their counterparts. Higher CKD in the diagnosed and treated reinforces the need for optimal control, which was low in this cohort.

Giant pulmonary artery aneurysm in long-standing chronic thromboembolic pulmonary hypertension.

Giant pulmonary artery aneurysm in long-standing chronic thromboembolic pulmonary hypertension.

Chronic kidney disease of unknown aetiology: A comprehensive review of a global public health problem.

The term chronic kidney disease of unknown aetiology (CKDu) refers to chronic kidney disease (CKD) in the absence of diabetes, long-standing hypertension, glomerulonephritis, obstructive uropathy or other apparent causes. An increasing number of CKDu cases have been reported from Latin America, Sri Lanka, India and others over the last two decades. These regional nephropathies share the following common attributes: (a) they affect low-to-middle income countries with tropical climates, (b) involve predominantly rural agricultural communities, (c) male predilection, (d) absence of significant proteinuria and hypertension, and (e) chronic tubulointerstitial nephritis on kidney biopsy. The current body of literature suggests that CKDu may be caused by heat stress, agrochemicals, contaminated drinking water or heavy metals; however, considerable regional disparities in CKDu research make it difficult to establish a common causal link. In the absence of a definite aetiology, specific preventive and therapeutic interventions are lacking. Improvement of working conditions of farmers and labourers, provision of safe drinking water and changes in agricultural practices are some of the measures that have been implemented; however, there is lack of data to assess their impact on the incidence and progression of CKDu. There is a need for a concerted global effort to address the current knowledge gaps, and to develop effective and sustainable strategies to tackle this devastating disease.

Left Laparoscopic Transperitoneal Adrenalectomy for Aldosteronoma

Primary hyperaldosteronism refers to the autonomous secretion of the hormone aldosterone from the adrenal gland, resulting in low renin levels. This usually occurs in individuals between the ages of 30 to 50 years old. The majority of these cases are caused either by a solitary, functioning adrenal adenoma or aldosteronoma (70%) or by idiopathic bilateral hyperplasia (30%). Other uncommon causes include adrenal carcinoma and familial hyperaldosteronism. Patients typically present with hypokalemia and long-standing hypertension that is difficult to control despite multi-drug therapy; nevertheless, further tests are required for diagnosis. An elevated plasma aldosterone level with a suppressed plasma renin level is strongly suggestive of the diagnosis. Once confirmed, further evaluation should be directed toward determining if the cause is a unilateral aldosteronoma or bilateral adrenal hyperplasia. This is done through imaging studies and adrenal vein sampling. Unilateral aldosteronoma is best managed by adrenalectomy, with the laparoscopic approach being the preferred method. Bilateral adrenal hyperplasia is often best treated medically, because only 20%–30% benefit from surgery. Here, we present the case of a 48-year-old woman who had long-standing hypertension and hypokalemia and was found to have hyperaldosteronism and low renin levels. A CT scan showed a small mass in the left adrenal gland, and adrenal vein sampling showed higher levels of aldosterone on the left side than on the right, confirming a unilateral aldosteronoma. Laparoscopic access was gained, the adrenal gland was exposed, dissected by controlling the periadrenal tissues with the harmonic scalpel, the adrenal vein was then ligated, and the adrenal gland was removed.

Transperitoneal Laparoscopic Right Adrenalectomy for Cortical Adenoma

Primary hyperaldosteronism, or Conn's syndrome, is a disease in which one or both adrenal glands produce excess amounts of aldosterone, leading to hypertension and hypokalemia. Common conditions resulting in this disorder include adenoma of the adrenal gland or hyperplasia of both adrenal glands. In rare cases, it is caused by malignant growth in the adrenal cortex or familial hyperaldosteronism. High blood pressure may cause headaches or blurred vision. Low potassium may cause fatigue, muscle cramps, muscle weakness, numbness, or temporary paralysis. Primary hyperaldosteronism is diagnosed by measuring serum levels of aldosterone, renin, and potassium. Patients classically have high aldosterone levels, suppressed renin levels, and low potassium levels. Once the diagnosis is established, localization of the source is performed using imaging studies. Adrenal vein sampling is also performed to determine more precisely and directly the side that is producing excess aldosterone. Primary hyperaldosteronism caused by an adrenal gland tumor is treated with adrenalectomy. Approximately 95% of patients will notice significant improvement in their hypertension after successful surgery. Here, we present the case of a 58-year-old woman with hypokalemia and long-standing hypertension refractory to medical treatment. Her blood tests showed high aldosterone levels and low renin levels, confirming the diagnosis of hyperaldosteronism. On CT scan, an adrenal nodule was noted on both sides. Adrenal vein sampling identified the right adrenal nodule as the cause. Laparoscopic access was gained, the adrenal gland was dissected and exposed, the adrenal vein ligated, and the adrenal gland was removed.

Teaching Neuro Images : Meningoencephalocele and CSF leak in chronic idiopathic intracranial hypertension

A 63-year-old woman with epilepsy and chronic headaches was admitted for status epilepticus. A lumbar puncture revealed increased opening pressure of 320 mm H2O and bacterial meningitis. MRI brain demonstrated a partial empty sella, tortuous optic nerve sheaths, flattening of the optic papillae, and numerous prominent arachnoid granulations, consistent with chronic idiopathic intracranial hypertension (IIH), as well as bright CSF signal and brain parenchyma within a left meningoencephalocele (figure, A). A CT cisternogram confirmed communication of the subarachnoid space of the meningoencephalocele with the left sphenoid sinus through a small osseous defect (figure, B). While most CSF leaks are related to trauma, IIH is increasingly recognized as a cause of spontaneous leaks.1,2 While the increased opening pressure may have been due to her acute meningitis, her headache symptoms and MRI findings are suggestive of longstanding intracranial hypertension. Monitoring and medical treatment of IIH must accompany surgical repair to avoid recurrence.2

Role of hypertension in progression of pediatric CKD.

Hypertension is frequent in children with chronic kidney disease (CKD). Its prevalence varies according to CKD stage and cause. It is relatively uncommon in children with congenital kidney disease, while acquired kidney disease is associated with a higher prevalence of hypertension. Studies in children with CKD utilizing ambulatory blood pressure monitoring also showed a high prevalence of masked hypertension. Uncontrolled and longstanding hypertension in children is associated with progression of CKD. Aggressive treatment of high blood pressure should be an essential part of care to delay CKD progression in children.

A challenging triple valve surgery for long-standing pulmonary hypertension in rheumatic heart disease: a case report

Background Pulmonary hypertension is an increase in the mean pulmonary arterial pressure, greater than 25mmHg at rest, or greater than 30mmHg while exercising. In valvular heart disease its presence indicates a decompensated state of the disease. Surgical interventions are the ultimate treatment for the correction of valvular heart disease. Case Report A 38-year-old female was admitted to the Emergency Department (ER) with complaints of shortness of breath, chest pain, palpitations, and history of fainting. The patient was initially scheduled for aortic and mitral valve replacement and tricuspid valve repair at the end of year 2020. However, due to covid-19 pandemic, the patient was re-scheduled for surgery. On the 15th of June 2022, the patient was admitted to the ER of Zainoel Abidin General Hospital, and was consulted to the CTVS division. On the 17th of June 2022, the patient underwent a successful mitral valve replacement using mechanical St. Jude 29 mm valve, mechanical St. Jude 17 mm for aortic valve position, and tricuspid valve repair commissurotomy and using MC3 Edward ring annuloplasty. The patient was hospitalized for seven days and underwent successful first phase cardiac rehabilitation before discharge. The patient has since made remarkable improvements, establishing better quality of life. Conclusion Reduced pulmonary pressures postoperatively are often modest, and persistent pulmonary hypertension (PH) is known to be common and an indicator of poor prognosis. For patients with long-standing pulmonary hypertension due to rheumatic heart disease, valve replacement surgery effectively reduces pulmonary hypertension caused by damage to the left heart valve.