1. HTN &Renal vascular disorders Ebadur Rahman FRCP (Edin),FRCPI,FASN, Specialty Certificate in Nephrology (UK) MRCP (UK), DIM (UK), DNeph (UK), MmedSciNephrology (UK). Consultant & clinical tutor Department of Nephrology Riyadh Armed Forces Hospital

2. Definition

5. 5 Impact of Hypertension 50 million individuals in the United States have hypertension 1 277,000 deaths annually in US due to hypertension 2 1 American Association of Clinical Endocrinologists Medical Guidelines For Clinical Practice for the Diagnosis and Treatment of Hypertension. Endocrine Practice, Vol 12 No. 2 March/April 2006 2 National Center for Health Statistics. Health, United States, 2005, with Chartbook on the Health of Americans. Hyattsville, Maryland: 2004. Available at: http://www.cdc.gov/nchs/hus.htmhttp://www.cdc.gov/nchs/hus.htm

7. Consequences of Hypertension Hypertension Brain Heart Kidney End-stage renal disease MI, heart failure, sudden death Stroke, dementia 1. Weir et al. Am J Hypertens 1999;12:205S-213S. 2. Beers MH, Berkow R, eds. The Merck Manual of Diagnosis and Therapy. 17th ed. 1999:1629-1648. 3. Francis CK. In: Izzo JL Jr, Black HR, eds. Hypertension Primer: The Essentials of High Blood Pressure. 2nd ed. 1999:175-176. 4. Hershey LA. In: Izzo JL Jr, Black HR, eds. Hypertension Primer: The Essentials of High Blood Pressure. 2nd ed. 1999:188-189. 7

9. 25 years 9 Admitted with fits BP 160/100

10. 10

11. Diagnosis Posterior reversible leuko ephalopathy 11

12. 40 years BP 150/80 normal biochemestry 12

13. 13

14. What to do Observe ACE Nephrectomy DIURETICS ATENOLOL 14

15. ACE

16. More than 80% essential HTN Renal causes of hypertension (2.5-6%) Polycystic kidney disease Chronic kidney disease Urinary tract obstruction Renin-producing tumor Liddle syndrome Endocrine cuases 1-2% Primary hyperaldosteronism Cushing syndrome Pheochromocytoma Congenital adrenal hyperplasia

17. 58 y BP 150/100 Calcium channel blocker ACE ARB DIURETICS ATENOLOL 17

18. Ace / arb

19. Modification Approximate SBP Reduction (range) Weight Reduction5-10 mmHg/10kg Adopt DASH eating plan8-14 mmHg Dietary sodium reduction2-8 mmHg Physical activity4-9 mmHg Moderation of alcohol consumption 2 – 4 mmHg Lifestyle Modifications

21. Resistant hypertension —16% American Heart Association defined - uncontrolled blood pressure in spite of concurrent use of 3 antihypertensive agents blood pressure is controlled with 4/ 4+ more medications. one of the three agents should be a diuretic and all agents should be prescribed at optimal doses 21

22. Pseudoresistant hypertension —20- 30% 22 1-Inaccurate measurement of blood pressure 2-Poor adherence to antihypertensive therapy. 3-White coat hypertension.

23. ISOLATED SYSTOLIC HYPERTENSION Defined as a systolic BP above 160 mmHg, with a diastolic BP below 90 mmHg. Defined as a systolic BP above 160 mmHg, with a diastolic BP below 90 mmHg. ISH mostly occurs ISH mostly occurs – in olderly ( 60 - 75 % ) ISH ISH – anemia, – hyperthyroidism, – aortic insufficiency, – arteriovenous fistula, – Paget disease of bone. ISH is associated with a 2- to 4 fold increase in the risk ISH is associated with a 2- to 4 fold increase in the risk – MI, LVH, renal dysfunction, stroke. 23

24. Diastolic hypertension — 24 DBP 90+ G oal diastolic pressure of 85 to 90 mmHg.

25. Importance of systolic & diastolic pressure — Among elderly patients, – HIGHER THE the systolic BP- risk coronary heart disease inversely with the diastolic pressure 25

26. MASKED HTN NORMAL CLINIC PRESURE BUT ABNORMAL WITH DAILY ACTIVITY 26

28. A 45-year-old man has just been found to have a persistently raised blood pressure. He considers himself a fit and healthy non- smoker and no other abnormalities were found during the examination. What investigations you would do?

29. Investigations for HTN

30. How often you will screen

33. The prevalence of renovascular hypertension less than 1 % in patients with mild hypertension but may be as high as 10 to 40 % – severe, or refractory hypertension

34. Types of RAS Atherosclerosis – – patients over the age of 45 years – involves the aortic orifice or the proximal main renal artery. – common in patients with diffuse atherosclerosis Fibromuscular dysplasia – – fibromuscular dysplasia (FMD) most often affects women under the age of 50 years – and typically involves the distal main renal artery or the intrarenal branches

40. Diagnosis

41. Some clinical clues A recent or rapid development of severe hypertension. sudden development of left ventricular failure (referred to as "flash pulmonary edema") Rapidly rising serum creatinine levels- following administration of angiotensin- converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs).

42. Magnetic resonance angiography — MR imaging (MR angiography) MR angiography had a sensitivity of 100 percent and specificity of 96 percent

43. Spiral CT scan with CT angiography — Spiral (helical) CT scan with intravenous contrast injec Spiral CT scan – sensitivity and specificity for renal artery stenosis of 98 and 94 percent, respectively..

46. Dopler Peak systolic velocity -specificity of 85 and 92 percent, respectively. It is time-consuming (taking up to two hours to perform). It is technically difficult, and is highly operator- dependent.

47. Resistive index — Duplex Doppler ultrasonography may predict eventual outcome with revascularization. 1 - end-diastolic velocity divided by peak systolic velocity. The outcomes were poor among the patients with resistive index values above 80: The outcomes were much better among the patients with a resistance index less than 80 who underwent successful revascularization.

48. renal vein renin measurements are no longer considered suitable for screening patients because of their poor sensitivity and specificity.

49. Plasma renin activity — The baseline plasma renin activity is elevated in only 50 to 80% The sensitivity and specificity of the captopril renin test has ranged in different studies from 75 to 100 percent and 60 to 95 percent, respectively captopril

50. Captopril renogram — Oral captopril (25 to 50 mg) is given one hour before the isotope is injected. The efficacy of this test is based upon the typical ACE inhibitor-induced decline in GFR in the stenotic kidney, – accompanied by an equivalent increase in GFR in the contralateral kidney due to removal of angiotensin II-mediated vasoconstriction. The net effect is that the difference between the two kidneys is enhanced. A marker of glomerular filtration, such as DTPA, or compounds that are secreted by the proximal tubule, such as hippurate and MAG3, have been used. MAG3 more reliable in patients with renal insufficiency

53. There are two major criteria for a positive ACE inhibitor renogram Decreased relative uptake with one kidney accounting for less than 40 percent of the total GFR. Delayed peak uptake of the isotope to more than 10 to 11 minutes, well above the normal value of three to six minutes. This criterion allows each kidney to be evaluated separately, making the detection of bilateral renovascular disease possible.

54. How ever most centers in US donot do this scan and preffer MRI OR CT ANGIO

55. Gold standard-angiogram Management issues

59. Three therapeutic options are available Medical therapy Percutaneous angioplasty with or without stent placement Surgery

65. Medical management

67. The largest trial, ASTRAL, included 806 patients with either unilateral or bilateral atherosclerotic renal artery stenosis who were randomly assigned to either medical therapy alone or medical therapy plus revascularization showed no significant difference between the two groups in the rate of progression of the serum creatinine (the primary end point) at a median follow-up of almost three years.

69. it is generally recommended that the following patients undergo renal artery revascularization Those with recent onset hypertension, younger patients – less likely to have underlying atherosclerotic disease, – significantly reduce the number of antihypertensive medications. Patients whose blood pressure cannot be lowered to the desired goal despite compliance with a reasonable medication regimen. Patients who are unable to tolerate antihypertensive Patients with loss of parenchymal mass from ischemic nephropathy.

70. WHICH OF THE FOLLOWING DRUG CAN CAUSE ACUTE RENAL SHUT DOWN IN BILATERAL RAS LABETOLOL AMLODIPINE NEMODIPINE NITROPRUSIDE Ace/arb

72. WHICH OF THE FOLLOWING DRUG CAN CAUSE ACUTE RENAL SHUT DOWN IN BILATERAL RAS LABETOLOL AMLODIPINE NEMODIPINE NITROPRUSIDE Ace/arb

73. Surgical revascularization should be considered if angioplasty fails who have multiple small renal arteries, early primary branching of the main renal artery, require aortic reconstruction near the renal arteries for other indications aneurysm repair or severe aortoiliac occlusive disease)

74. Thank you