Cause Of Secondary Hypertension Research Articles

SECONDARY HYPERTENSION IN THE INTERNAL MEDICINE OUTPATIENT DEPARTMENT OF A PORTUGUESE HOSPITAL

Objective: Secondary hypertension is an uncommon form of hypertension and universal screening is not beneficial or cost-effective. Consequently, investigation is reserved for selected cases, according to clinical suspicion, and is often referred to a specialist. The aim of this study was to characterize the evaluation of secondary hypertension in the Internal Medicine Outpatient Department of a portuguese hospital. Design and method: This longitudinal retrospective study analysed patients referred to our Internal Medicine Outpatient Department for hypertension evaluation in 2021. Patient records and results were analysed, focusing on indication for evaluation, testing performed and identified causes of secondary hypertension. Results: A total of 147 patients were referred for hypertension evaluation, 7 (4,76%) of which were explicitly referred for secondary hypertension screening. Testing was conducted in 105 patients (71,43%), with basic evaluation (CBC, renal function, thyroid function) in 71 patients (48,30%) and additional testing (such as endocrine, renovascular, obstructive sleep apnoea screening) performed in 34 patients (23,13%). Considering age criteria, resistant hypertension, and other clinical clues, 60 patients (40,82%) had a documented indication for additional testing for secondary hypertension. Additional testing was requested in 5 patients (3,40%) not meeting these criteria, most of whom needed testing to follow-up investigations ordered in primary care without clear indication. Conversely, a small proportion (6,12%) met criteria for additional testing that wasn’t requested: 22% already had a previous screening ordered in primary care negative for secondary hypertension; 44% were evaluated for hypertension-mediated organ damage without further screening. Patients in which specific evaluation was complete at the time of this study, a secondary cause was identified in 9 patients (6.12%), all with a previous diagnosis of Obstructive Sleep Apnea. Conclusions: The prevalence of secondary forms identified didn’t significantly differ from the described 5-10% overall prevalence of secondary hypertension and reiterated the identification of OSA as an exceedingly common recognized cause of hypertension. This study emphasised that extensive testing was mostly non-diagnostic and was associated with inconclusive results leading to further investigations, raising costs and risks. This suggests that careful selection of patients and method of screening by a specialist is beneficial.

Triple retinal arterial macroaneurysms in a hypertensive patient with hypothyroidism

PurposeTo present the unique case of numerous, recurring retinal arterial macroaneurysms (RAMs) in a hypothyroid patient with hypertension.Methods67-year-old woman’s clinical findings, laboratory results, fundus fluorescein angiography, optical coherence tomography (OCT), and optical coherence tomography angiography (OCTA) are given. Over a two-year period, the patient was monitored.ResultsA 67-year-old woman presented to the outpatient clinic with vitreous and dense subretinal hemorrhages in her right eye. RAM rupture was discovered along the suprotemporal retinal arteriole. A diagnosis of systemic arterial hypertension was made. Two months later, the vitreous hemorrhage spontaneously resolved and the patient’s vision improved. After nine months of initial presentation, the patient developed another RAM. Meanwhile the patient developed ichthyosis caused by hypothyroidism. Because fundus fluorescein angiography revealed that the first RAM was still active, an intravitreal injection of anti-VEGF was administered six months afterwards. More proximal RAM with macular edema developed after another six months necessitating laser photocoagulation. However macular edema didn’t resolve and a second injection of intravitreal anti-VEGF was given.ConclusionsPatients with RAMs, particularly if multiple or recurring, should be thoroughly investigated and assessed, particularly for secondary causes of hypertension. OCT and OCTA are useful tools for RAM confirmation and follow-up. It is important to look into how RAM behavior interacts with coexisting macular edema, and other variables affecting hemodynamic status.

Predictive performance of aldosterone-to-renin ratio in the diagnosis of primary aldosteronism in patients with resistant hypertension.

The systematic use of confirmatory tests in the diagnosis of primary aldosteronism (PA) increases costs, risks and complexity to the diagnostic work-up. In light of this, some authors proposed aldosterone-to-renin (ARR) cut-offs and/or integrated flow-charts to avoid this step. Patients with resistant hypertension (RH), however, are characterized by a dysregulated renin-angiotensin-aldosterone system, even in the absence of PA. Thus, it is unclear whether these strategies might be applied with the same diagnostic reliability in the setting of RH. We enrolled 129 consecutive patients diagnosed with RH and no other causes of secondary hypertension. All patients underwent full biochemical assessment for PA, encompassing both basal measurements and a saline infusion test. 34/129 patients (26.4%) were diagnosed with PA. ARR alone provided a moderate-to-high accuracy in predicting the diagnosis of PA (AUC=0.908). Among normokalemic patients, the ARR value that maximized the diagnostic accuracy, as identified by the Youden index, was equal to 41.8 (ng/dL)/(ng/mL/h), and was characterized by a sensitivity and a specificity of 100% and 67%, respectively (AUC=0.882); an ARR > 179.6 (ng/dL)/(ng/mL/h) provided a 100% specificity for the diagnosis of PA, but was associated with a very low sensitivity of 20%. Among hypokalemic patients, the ARR value that maximized the diagnostic accuracy, as identified by the Youden index, was equal to 49.2 (ng/dL)/(ng/mL/h), and was characterized by a sensitivity and a specificity of 100% and 83%, respectively (AUC=0.941); an ARR > 104.0 (ng/dL)/(ng/mL/h) provided a 100% specificity for the diagnosis of PA, with a sensitivity of 64%. Among normokalemic patients, there was a wide overlap in ARR values between those with PA and those with essential RH; the possibility to skip a confirmatory test should thus be considered with caution in this setting. A better discriminating ability could be seen in the presence of hypokalemia; in this case, ARR alone may be sufficient to skip confirmatory tests in a suitable percentage of patients.

An Abbreviated History of Aldosterone Metabolism, Current and Future Challenges.

The initial isolation of adrenal steroids from large quantities of animal adrenals resulted in an amorphous fraction resistant to crystallization and identification and had potent effects on electrolyte transport. Aldosterone was eventually isolated and identified in the fraction and was soon shown to cause hypertension when in excess. The autonomous and excessive production of aldosterone, primary aldosteronism, is the most common cause of secondary hypertension. Aldosterone is metabolized in the liver and kidney, and its metabolites are conjugated with glucuronic acid for excretion. The most common liver metabolite is 3α,5β-tetrahydroaldosterone-3-glucuronide, while that of the kidney is aldosterone-18-oxo-glucuronide. In terms of their value, especially the aldosterone-18-oxo-glucuronide, is commonly used for the diagnosis of primary aldosteronism because they provide an integrated value of the total daily production of aldosterone. Conversion of aldosterone to 18-oxo-glucuronide is impeded by drugs, like some common non-steroidal anti-inflammatory drugs that compete for UDP-glucuronosyltransferase-2B7, the most important glucuronosyltransferase for aldosterone metabolism. Tetrahydroaldosterone is the most abundant metabolite and the most reliable for the diagnosis of primary aldosteronism, but it is not commonly measured.

Indication, performance and outcomes of adrenal vein sampling in patients with primary hyperaldosteronism

Primary hyperaldosteronism (PAH) is an important cause of secondary hypertension (HTN). The study of the same requires a high clinical suspicion in addition to a hormonal study that confirms hormonal hypersecretion. It is important to start the appropriate treatment once the diagnosis is confirmed, and for this is necessary to demonstrate whether the hormonal hypersecretion is unilateral (patients who could be candidates for surgical treatment) or bilateral (patients who are candidates for pharmacological treatment only).At the Hospital del Mar since 2016 there has been a multidisciplinary work team in which Nephrologists, Endocrinologists, Radiologists and Surgeons participate to evaluate cases with suspected hyperaldosteronism and agree on the best diagnostic-therapeutic approach for these patients, including the need for adrenal vein sampling, which is a technique that in recent years has become the gold standard for the study of PAH.In the present study we collect the experience of our centre in performing AVC and its usefulness for the management of these patients.

Pregnancy complicated by juxtaglomerular cell tumor of the kidney: A case report

Juxtaglomerular cell tumor (JGCT) of the kidney, also known as reninoma, is a rare renal tumor that typically clinically manifests as hypertension, hypokalemia, high renin, and high aldosterone. It is a cause of secondary hypertension. Pregnancy with JGCT is rarer and easily misdiagnosed as pregnancy-induced hypertension, thus affecting treatment. A 28-year-old woman presented in early pregnancy with hypertension (blood pressure of 229/159 mmHg), nausea, and occasional dizziness and headache. The patient was diagnosed with pregnancy-induced hypertension, and no relief was found after symptomatic treatment; hence, the pregnancy was terminated by artificial abortion. Her blood pressure remained high following termination of pregnancy. Blood tests suggested hypokalemia (2.997 mmol/L), blood aldosterone measured 613 ng/L, and computed tomography urography showed a tumor in the right kidney. Therefore, laparoscopic partial nephrectomy was performed. After surgery, the patient's blood pressure returned to normal, and blood potassium, aldosterone, and renin normalized. Postoperative pathological examination revealed JGCT. After long-term follow-up, the patient became pregnant again 6 mo after surgery. No hypertension occurred during pregnancy, and the patient delivered a healthy female neonate. Patients with pregnancy complicated by JGCT are difficult to diagnose. Herein, we advise surgeons on proper handling of such situations.

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.

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.