Cause Of Secondary Hypertension Research Articles

Unusual presentation of subcapsular renal pseudocyst as page kidney – A case report

Page kidney is a rare but potentially curable cause of secondary hypertension. While the pancreatic pseudocyst is a completely different and unrelated entity. Here, we report a case of a 45-year-old female, diagnosed with idiopathic acute pancreatitis with multiple pseudocysts. After successful ultrasound -guided drainage of her left subcapsular renal pseudocyst, she became normotensive again, confirming the diagnosis of page kidney. This case highlights dual reasons that prompted us to report the case. The first being such remotely located subcapsular renal pseudocyst as itself a rare entity and the second, its unusual presentation as page kidney. The case emphasizes on the early management of such patients so as to salvage renal function.

Triptorelin-Induced Delayed Transient Arterial Hypertension

Background: Gonadotropin-releasing hormone analogs (GnRHas) such as triptorelin have been found to be effective and safe in the suppression of central precocious puberty (CPP). Only minor and transient side effects have been reported with depot preparation used in children. Clinical Description: We present three children with CPP who developed late onset hypertension 18–24 months after starting triptorelin, a long-acting GnRHa depot preparation. The secondary causes of hypertension were ruled out on the basis of clinical findings, appropriate blood tests, echocardiography, and abdominal ultrasound. Management and Outcome: After starting therapy with GnRHa, the children were evaluated routinely every 2–3 months for the 1st year, then every 6 months. They developed hypertension between 18 and 24 months after starting triptorelin. While therapy with triptorelin was stopped in all three children, only one of them was prescribed antihypertensive drug. The hypertension resolved gradually after discontinuation of triptorelin in all the children and antihypertensive was also omitted in the single case. Conclusion: Hypertension may be an adverse effect of triptorelin therapy and thus regular monitoring of blood pressure in children undergoing therapy with this drug for CPP is warranted.

Predictive Factors for Complete Resolution of Hypertension After Adrenalectomy for Aldosteronoma

Introduction: Primary hyperaldosteronism, 1st cause of secondary hypertension, 2nd cause of hypertension potentially curable by surgery. The objective of this work is to determine the predictive factors for complete resolution of hypertension after adrenalectomy. Material: We conducted a retrospective study of 25 patients with primary hyperaldosteronism operated and followed between 1985 and 2018. Results: Our patients were divided into 16 women and 9 men, mean age 54 years. 40% of our patients were smokers, 36% dyslipidemic, 68% diabetic and 76% had a BMI ≥ 25 kg / m2. Patients underwent unilateral adrenalectomy, the surgical approach was posterior lumbar in 9 cases and laparoscopic in 16 cases. No per or postoperative complication was noted. The postoperative course was marked by the HTA in 36% of the cases, an improvement in 36% of the cases and persistence in 31% of the cases. We found a significant decrease of the PAS and the PAD at six months of the surgery. The comparative study of the patients whose HTA was cured versus unhealed did not show a statistically significant correlation with the following predictors of healing: young age, female gender, lack of family history of hypertension, adenoma’s dimension, the presence of comorbidities including diabetes and dyslipidemia and the average number of antihypertensive treatment.Only the absence of overweight or obesity was a predictor of healing in our series. Conclusion: Knowing the predictive factors of healing aims to pose the operative indication and especially to improve the prognosis of hypertension after surgery by acting on certain modifiable factors.

IgA nephropathy – one of the possible causes of malignant hypertension

Malignant hypertension (MH) is a state which can rapidly progress to multi-organ failure. It can develop in the course of both primary and secondary type of hypertension. In our study, we present a case of a 36-year-old man diagnosed with renal failure and MH complicated with retinopathy. As the secondary nature of the condition was suspected extensive diagnostics has been conducted. In spite of excluding plenty of pathologies, the underlying cause remained unknown. Eventually, the renal biopsy has been performed, leading to a diagnosis of IgA nephropathy. However, symptoms and course of the disease has not been typical. Nevertheless, IgA nephropathy should be considered as a possible cause of secondary hypertension as well as malignant hypertension. The diagnosis is not easy and a crucial role is played by renal biopsy.

Stent-Graft Placement for Radiation-Induced Abdominal Aortic Stenosis after Renal Autotransplantation.

Renovascular hypertension (RVH) is a common cause of secondary hypertension. However, there have been no reports on RVH due to radiation-induced abdominal aorta stenosis after renal autotransplantation. A 27-year-old woman with a history of neuroblastoma treated by radiation therapy and RVH treated with renal autotransplantation presented with hypertension and dyspnea. At age 19, she had experienced hypertensive heart failure due to RVH from radiation-induced left renal artery stenosis and had undergone renal autotransplantation involving the extraction of her left kidney. Her systolic blood pressure (BP) was well-controlled but had increased progressively. She was diagnosed with hypertensive heart failure and admitted to hospital. Although her dyspnea soon subsided after treatment, her BP remained high. Renal artery ultrasound revealed no obvious stenosis. The ankle brachial pressure index (ABI) showed a significant bilateral decrease to 0.71/0.71 (right/left) from 0.94/0.95 eight years before. Magnetic resonance angiography and aortic angiography revealed severe stenosis in the abdominal aorta, and the systolic pressure gradient of intra-aortic blood flow, distal and proximal to a stenotic lesion, was 58 mmHg. These arterial stenoses in the irradiated area were highly suggestive of radiation-induced vasculopathy. She finally underwent an endovascular VIABAHN VBX balloon-expandable stent-graft placement for this radiation-induced abdominal aorta stenosis, which resolved the pressure gradient. After the procedure, her ABI improved to 0.91/0.88 and her BP was well-controlled. This is the first case of successful stent-graft placement for RVH after renal autotransplantation due to radiation-induced abdominal aorta stenosis as a consequence of neuroblastoma.

Primary aldosteronism: an unsuspected culprit of hypertension in systemic lupus erythematosus?

Primary aldosteronism (PA) is the most common endocrine cause of secondary hypertension and is associated with a high risk of cardiovascular disease in the general population. Patients suffering from systemic lupus erythematosus (SLE), a multisystem and multifactorial autoimmune disease, experience a high burden of hypertension and cardiovascular disease. Importantly, cardiovascular disease is one of the leading causes of death in SLE. Very limited evidence suggests an increased proportion of autoimmune diseases such as SLE in patients with PA. However, studies evaluating the prevalence of PA in the SLE population are lacking. Despite the potential for curative or targeted treatments, guidelines for the management of hypertension in SLE do not currently recommend testing for PA. This review highlights PA as a potentially over-looked secondary cause of hypertension in SLE, and offers future directions in research to improve the detection of this highly modifiable cardiovascular risk factor in the SLE population.

NONALCOHOLIC FATTY LIVER DISEASE AND RISK OF INCIDENT HYPERTENSION: A SYSTEMATIC REVIEW

NAFL, or Non-Alcoholic Fatty liver, is a disorder characterized by the presence of steatosis; steatosis, an inflammation and expansion of liver cells with or without liver fibrosis (NASH, Non-Alcoholic Steatohepatosis); and cirrhosis. If more fibrosis or cirrhosis develops, the potential risk of liver cancer will grow. Current epidemiological research indicates that around 49.5% of people with hypertension also have NAFLD. In addition, the prevalence of hypertension is significantly higher in patients with NAFLD than in the general population. It has been proven that both the presence of NAFLD and the severity of the illness are significantly associated with higher risks of a broad spectrum of extrahepatic effects, including cardiovascular disease (CVD) and type 2 diabetes mellitus. Hypertension is a disorder characterized by multiple medical issues. In the majority of patients, the pathophysiological cause is unknown (essential or primary). Primary hypertension is incurable but can be managed. Another group with a low percentage has a unique cause, which is known as secondary hypertension. Endogenous and exogenous causes of secondary hypertension are numerous. If the source of secondary hypertension can be discovered, these patients' hypertension may be curable. All studies demonstrate that persons with NAFLD are more likely to have hypertension than those without NAFLD.

Sublethal Hyperthermia Transiently Disrupts Cortisol Steroidogenesis in Adrenocortical Cells.

Primary aldosteronism is the most common cause of secondary hypertension. The first-line treatment adrenalectomy resects adrenal nodules and adjacent normal tissue, limiting suitability to those who present with unilateral disease. Use of thermal ablation represents an emerging approach as a possible minimally invasive therapy for unilateral and bilateral disease, to target and disrupt hypersecreting aldosterone-producing adenomas, while preserving adjacent normal adrenal cortex. To determine the extent of damage to adrenal cells upon exposure to hyperthermia, the steroidogenic adrenocortical cell lines H295R and HAC15 were treated with hyperthermia at temperatures between 37 and 50°C with the effects of hyperthermia on steroidogenesis evaluated following stimulation with forskolin and ANGII. Cell death, protein/mRNA expression of steroidogenic enzymes and damage markers (HSP70/90), and steroid secretion were analyzed immediately and 7 days after treatment. Following treatment with hyperthermia, 42°C and 45°C did not induce cell death and were deemed sublethal doses while ≥50°C caused excess cell death in adrenal cells. Sublethal hyperthermia (45°C) caused a significant reduction in cortisol secretion immediately following treatment while differentially affecting the expression of various steroidogenic enzymes, although recovery of steroidogenesis was evident 7 days after treatment. As such, sublethal hyperthermia, which occurs in the transitional zone during thermal ablation induces a short-lived, unsustained inhibition of cortisol steroidogenesis in adrenocortical cells in vitro.

Primary aldosteronism during pregnancy and eplerenone use – a case report

Primary aldosteronism is one of the important causes of secondary hypertension. However, pregnancy with primary aldosteronism is rare. Eplerenone is an aldosterone antagonist which is used in the treatment of primary aldosteronism. This is a case of successful pregnancy outcome in a young woman who was known to have primary aldosteronism and was on oral eplerenone from preconception. There are only five case reports on eplerenone use during pregnancy in the literature.

Prevalence of High Aldosterone-Renin Ratio in Patients With Hypertension in Basrah.

Aldosterone-renin ratio (ARR) is an important screening tool for the assessment of primary aldosteronism as a cause of secondary hypertension. This study aimed to measure the prevalence of patients with elevated ARR among samples of Iraqi patients with hypertension. A retrospective study was conducted at Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC) in Basrah during the period of February 2020 to November 2021. We evaluated the records of patients with hypertension whom were screened for endocrine cause, and an ARR cut-off equal or more than 5.7 was considered elevated. Of the total 150 patients enrolled, 39 (26%) of them had an elevated ARR. No statistically significant association for the elevated ARR with age, gender, BMI, duration of hypertension, systolic and diastolic blood pressure, pulse rate, and presence or absence of diabetes mellitus or lipid profile. High frequency of elevated ARR was seen in 26% of patients with hypertension. More studies need to be conducted in the future taking larger samples.

The Effect of Aldosterone on Cardiorenal and Metabolic Systems

Aldosterone, a vital hormone of the human body, has various pathophysiological roles. The excess of aldosterone, also known as primary aldosteronism, is the most common secondary cause of hypertension. Primary aldosteronism is associated with an increased risk of cardiovascular disease and kidney dysfunction compared to essential hypertension. Excess aldosterone can lead to harmful metabolic and other pathophysiological alterations, as well as cause inflammatory, oxidative, and fibrotic effects in the heart, kidney, and blood vessels. These alterations can result in coronary artery disease, including ischemia and myocardial infarction, left ventricular hypertrophy, heart failure, arterial fibrillation, intracarotid intima thickening, cerebrovascular disease, and chronic kidney disease. Thus, aldosterone affects several tissues, especially in the cardiovascular system, and the metabolic and pathophysiological alterations are related to severe diseases. Therefore, understanding the effects of aldosterone on the body is important for health maintenance in hypertensive patients. In this review, we focus on currently available evidence regarding the role of aldosterone in alterations of the cardiovascular and renal systems. We also describe the risk of cardiovascular events and renal dysfunction in hyperaldosteronism.

Pheochromocytoma Presenting with Upper GI Symptoms: A Case Report

Pheochromocytomas are rare tumours originating in chromaffin cells, representing 0.1–1% of all secondary hypertension cases.1 A case of pheochromocytoma in a 34 year old male presenting with unusual symptoms of abdominal discomfort and vomiting is presented. He has been generally well in the past but started feeling excessively tired for last 4 years and had dyspepsia off and on. On presentation his blood pressure was 240/120 mmHg, and heart rate was 130bpm. There was no neurological deficit and rest of the physical examination was normal. Fundoscopic examination revealed copper wiring and AV nipping but no hemorrhages or papilledema.The aim of this case report is to emphasize the importance of secondary causes of hypertension and to keep in mind the unusual presenting symptoms of pheochromocytoma. Keywords: Gastrointestinal Disorders, Pheochromocytoma, Tumors

Cardiac structure and function in resistant hypertension: The beneficial role of blood pressure control.

Cardiac structure and function in resistant hypertension: The beneficial role of blood pressure control.

Ketosis, Salt, and Water: Novel Mechanistic Insights into Diet and Mineralocorticoid Metabolism.

The association between dietary macronutrient composition and cardiovascular health has been studied extensively for decades (1, 2). High dietary sodium intake has traditionally been linked with cardiovascular disease and mortality, although recent data suggest that this association may be negligible where mean intake is less than 5 g/day. The renin-angiotensin-aldosterone system (RAAS) is a key regulator of circulating blood volume, as well as sodium and potassium homeostasis. Renin production from the renal juxtaglomerular apparatus is stimulated by reduced circulating blood volume, thereby stimulating aldosterone secretion from zona glomerulosa cells of the adrenal cortex. Primary aldosteronism, due to a unilateral aldosterone-producing adenoma (Conn's syndrome) or bilateral hyperplasia of the glomerulosa, is an important cause of secondary hypertension and has independent associations with cardiovascular disease (3). In the absence of autonomous aldosterone production, antagonism of the mineralocorticoid receptor is a key therapeutic approach in hypertension and heart disease by lowering blood pressure and improving cardiac remodeling.

Genetic Risk of Primary Aldosteronism and Its Contribution to Hypertension: A Cross-Ancestry Meta-Analysis of Genome-Wide Association Studies.

Hypertension imposes substantial health and economic burden worldwide. Primary aldosteronism (PA) is one of the most common causes of secondary hypertension, causing cardiovascular events at higher risk compared with essential hypertension. However, the germline genetic contribution to the susceptibility of PA has not been well elucidated. We conducted a genome-wide association analysis of PA in the Japanese population and a cross-ancestry meta-analysis combined with UK Biobank and FinnGen cohorts (816 PA cases and 425 239 controls) to identify genetic variants that contribute to PA susceptibility. We also performed a comparative analysis for the risk of 42 previously established blood pressure-associated variants between PA and hypertension with the adjustment of blood pressure. In the Japanese genome-wide association study, we identified 10 loci that presented suggestive evidence for the association with the PA risk (P<1.0×10-6). In the meta-analysis, we identified 5 genome-wide significant loci (1p13, 7p15, 11p15, 12q24, and 13q12; P<5.0×10-8), including 3 of the suggested loci in the Japanese genome-wide association study. The strongest association was observed at rs3790604 (1p13), an intronic variant of WNT2B (odds ratio, 1.50 [95% CI, 1.33-1.69]; P=5.2×10-11). We further identified 1 nearly genome-wide significant locus (8q24, CYP11B2), which presented a significant association in the gene-based test (P=7.2×10-7). Of interest, all of these loci were known to be associated with blood pressure in previous studies, presumably because of the prevalence of PA among individuals with hypertension. This assumption was supported by the observation that they had a significantly higher risk effect on PA than on hypertension. We also revealed that 66.7% of the previously established blood pressure-associated variants had a higher risk effect for PA than for hypertension. This study demonstrates the genome-wide evidence for a genetic predisposition to PA susceptibility in the cross-ancestry cohorts and its significant contribution to the genetic background of hypertension. The strongest association with the WNT2B variants reinforces the implication of the Wnt/β-catenin pathway in the PA pathogenesis.

Case Report: Diagnosis and Management of Long-Standing Essential Hypertension on a Teenager

Background: Hypertension affects about one third of the worldwide adult population, in patients aged 18 to 39, prevalence of hypertension is 7.3%. The risk factors for primary hypertension in young adults are the same as in older adults, which include family history of hypertension, poor diet with excess intake of sodium, lack of physical activity, obesity and excess intake of alcohol or tobacco smoking. The treatment of choice for essential hypertension in young adult are lifestyle changes but there is no consensus on the role pharmacological treatment in young hypertensives. The Case: A 19–year–old patient present with a worsening five–year history of palpitations felt in the abdominal region, tachycardia and high blood pressure. He had a body mass index of 31.3 kg/m2, suboptimal diet and level of physical activity (though he was previously very active) and a family history of essential hypertension. Possible secondary causes of hypertension were ruled out and a diagnosis of essential hypertension was reached through 24–hour ambulatory blood pressure monitoring. The patient was treated with a combination of 5mg amlodipine and 5mg bisoprolol per day as well as lifestyle changes. Conclusion: This case highlights the increasingly young age of presentation of essential hypertension, especially since the patient refers presence of symptoms as early as 14 years old when he had a relative lack of risk factors. It is important to rule out other potential causes of hypertension in young adults before making a diagnosis of essential hypertension.

RAS-challenge as a first-look test for detection of primary aldosteronism in patients with treatment-resistant hypertension

Purpose Primary aldosteronism (PA), characterised by low-renin hypertension, confers a high cardiovascular risk and is the most common cause of secondary hypertension, with an increased prevalence in patients with treatment-resistant hypertension. However, it is estimated that only a small percentage of affected patients are identified in routine clinical practice. Inhibitors of the renin-angiotensin system cause an increase in renin levels in patients with intact aldosterone regulation, and inadequate low renin with concurrent RAS inhibition (RASi) may therefore indicate PA, which could serve as a first look screening test for selection for formal work-up. Methods We analysed patients between 2016–2018 with treatment-resistant hypertension who had inadequate low renin in the presence of RASi (i. e. at risk for PA) and who were offered systematic work-up with adrenal vein sampling (AVS). Results A total of 26 pts were included in the study (age 54.8 ± 11, male 65%). Mean office blood pressure (BP) was 154/95 mmHg on 4.5 antihypertensive drug classes. AVS had a high technical success rate (96%) and demonstrated unilateral disease in the majority of patients (57%), most of which (77%) were undetected by cross-sectional imaging. Conclusion In patients with resistant hypertension, low renin in the presence of RASi is a strong indicator for autonomous aldosterone secretion. It may serve as an on-medication screening test for PA to select for formal PA work up.

Pitfalls in the diagnosis and treatment of a hypertensive patient with unilateral primary aldosteronism and contralateral pheochromocytoma: a case report

BackgroundPrimary aldosteronism (PA) is a common cause of secondary hypertension, whereas pheochromocytoma is a rare cause of it. Thus, concomitant PA and pheochromocytoma is a very rare condition.Case presentationA 52-year-old woman was admitted to our hospital with suspected PA based on the presence of hypertension, spontaneous hypokalemia, and a high aldosterone-to-renin ratio. She had no catecholamine excess symptoms other than hypertension. Abdominal computed tomography (CT) showed a right lipid-rich adrenal mass and a left lipid-poor adrenal mass. PA was diagnosed by the captopril challenge test. The 24-h urinary fractionated metanephrines were slightly elevated. Adrenal vein sampling (AVS) confirmed that the right adrenal gland was responsible for aldosterone hypersecretion. Medical therapy with eplerenone was started because the patient refused surgery. Five years later, she requested surgery for PA. The second AVS confirmed right unilateral hyperaldosteronism, as expected. Repeated abdominal CT showed the enlargement of the left adrenal mass. The 24-h urinary fractionated metanephrines had risen to the diagnostic level. 123I- metaiodobenzylguanidine (MIBG) scintigraphy showed a marked tracer uptake in the left adrenal mass with no metastatic lesion. After preoperative management with α-blockade, laparoscopic left partial adrenalectomy was performed. Immunohistochemical examination of the tumor showed chromogranin A positivity leading to the diagnosis of left pheochromocytoma.ConclusionsWe report an extremely rare case of concomitant unilateral PA and contralateral pheochromocytoma. When diagnosing unilateral PA by AVS, especially in cases with a lipid-poor adrenal mass, clinicians should rule out the possibility of the presence of pheochromocytoma before proceeding to undergo unilateral adrenalectomy. Although there is no standard treatment for this rare condition, it is essential to select personalized treatment from the perspective of conserving the adrenal gland.

Bilateral Page kidney in a postpartum female: a case report.

A 35-year P1 with gestational hypertension presented with a persistent postpartum elevation of blood pressure (BP). Imaging studies revealed bilateral renal subcapsular hematoma (left>right). She was managed with an angiotensin receptor blocker initially and ultrasound-guided percutaneous drainage of the collection for the optimal control of elevated BP. Ultrasonography and computed tomography of the kidneys are the most frequently used for diagnosing a Page kidney. Medical management with antihypertensive and regular follow-ups form the first line of treatment in Page kidneys. Percutaneous drainage, surgical decortication, laparoscopic intervention, and nephrectomy are necessary in cases of organized late hematomas. Spontaneous bilateral Page kidney is a rare but potentially treatable and curable form of hypertension. Percutaneous drainage is an effective method to drain the hematoma and control elevated BP.

The effect of age, sex and BMI on the aldosterone-to-renin ratio in essential hypertensive individuals.

The aldosterone-to-renin ratio (ARR) is widely used as a screening test for primary aldosteronism, but its determinants in patients with essential hypertension are not fully known. The purpose of the present investigation is to identify the impact of age, sex and BMI on renin, aldosterone and the ARR when measured under strict, standardized conditions in hypertensive patients without primary aldosteronism. We analysed the data of 423 consecutive hypertensive patients with no concomitant cardiac or renal disorders from two different hospitals (Rotterdam and Maastricht) who had been referred for evaluation of their hypertension. Those who were diagnosed with secondary causes of hypertension, including primary aldosteronism, were excluded from analysis. Patients who used oral contraceptives or had hormonal replacement therapy were excluded as well. Plasma aldosterone concentration (PAC), active plasma renin concentration (APRC) and the ARR were measured under standardized conditions. All measurements were taken in the supine position at 10.00 h in the morning, with one subgroup of patients adhering to a sodium-restricted diet (55 mmol/day) for no less than 3 weeks, and the other subgroup maintaining an ad libitum diet. In those who were receiving antihypertensive treatment, all medications were discontinued at least 3 weeks before testing. In neither group did aldosterone correlate with age. Renin, however, was inversely related to age both during low-salt diet ( P < 0.001) and during ad lib salt intake ( P = 0.05). This resulted in a significant positive correlation between age and the ARR in both groups. Although on both dietary regimens, PAC and APRC were significantly higher in men when compared with women, the ARR was not significantly different between the two sexes. The age-relationships of renin and the ARR were comparable in men and women on both diets, albeit with greater variability in women. There was an upward trend between BMI and the ARR, which reached statistical significance only in men on low-salt diet. In multivariable regression analysis, age remained the only independent determinant of the ARR. In our essential hypertensive population, the ARR increased significantly with age but was not affected by sex or BMI.