RENAL

HYPERTENSION

dr. Jodi Sidharta Loekman, Sp.PD-KGH,

FINASIM
Introduction
Most human hypertension remains
unknown, is called essential or primary
hypertension.
5-10% cases arise from known cause
secondary hypertension.
Sometimes cured if identified.
Etiology
Renal disease Alcoholism
Estrogen and Brain Lesion
eclampsia Cushing syndrome
Coarctation of Drugs
aorta Endocrine diseases
Aldosteronism
Pheochromocytom
a
Sleep apnea
Renal Disease
Renal Disease
Mechanisms consist of:
Acute kidney injury (AKI): Via retention of
excess sodium and water increasing
blood volume volume-dependent
hypertension
Renovascular disease: Via secretion of
greater than normal amounts of renin
(renal artery stenosis raises pressure)
Renal Parenchymal Disease: via difuse
artherosclerotic of small arteries ,chronic
renal ischemic,nephron loss ,RAAS
stimulation,water and sodium retention.
Renovascular Disease
1-3 % hypertension cases caused by renal
artery stenosis
Reduced renal blood flow renin released
Possible pathologic cause of stenosis
Atherosclerosis
Fibromuscular dysplasia ( young - middle-aged
female)
Neurofibromatosis ( children)
Other cause, such as emboli, inflammatory
lesions, tumor/cyst, kinking after transplantation
Hemodynamic changes in renovascular
hypertension

Renal hypoxia

Renin Angiotensin Aldosterone

Blood Peripheral Sodium

pressure resistance retention

Autoregulation

Cardiac Cardiac
output output

inhibits
Diagnosis
Onset : before 25 yo or after 50 yo, especially
without family history of hypertension
Rapid worsening of preexisting hypertension,
especially when there is other vascular
disease
Very severe hypertension requiring multiple
drugs
Coexistence of severe hypertension and
impaired renal function
Reccurent pulmonary edema without obvious
cardiac cause
Renovascular HTN -
principles
Not all RAS causes HTN or ischemic nephropathy
Differing etiology of RAS has different outcomes
in regards to treatment (FMD vs atherosclerosis)
No current rationale for drive-by interventions
Importance of medical rx
No current consensus guidelines for
screening/outcomes/treatment ( as opposed to
carotid artery stenosis, AAA, etc)
Renovascular HTN

Coffman TM, Schriers Diseases of The

Diagnosis (2)
Physical examination: abdominal bruit
Arteriography , Magnetic resonance
angiography, CT Angiography, Duplex
ultrasonography, Renogram
Renal vein renin measurement
Coffman TM, Schriers Diseases of The
Treatment
Transluminal renal angioplasty
Surgery
Medication
ACE-I or ARB work well in unilateral renal
artery stenosis and contraindicated in
bilateral stenosis
 Fibromuscular Dysplasia, before
and after PTRA

Atherosclerotic RAS before and after stent

Safian & Textor. NEJM 344:6;
Coffman TM, Schriers Diseases of The
Summary
Renal artery stenosis causes 1-3% of hypertension
cases
Physiologically significant blockage is suggested
by 75% - 90% decrease in renal artery diameter.
Atherosclerosis is the most common cause of
renal artery stenosis in adult
Gold standard imaging is contrast arteriography
The presence of stenosis doesnt prove that it
cause hypertension
Treatment consists of drugs, intra-arterial balloon,
or vascular surgery.
Renal Parenchymal Disease
Acute kidney injury damage to the
juxtaglomerular cell induce
juxtaglomerular cell to release renin.
Hypertension usually subsides as the
acute disease clears.
Etiology
Acute kidney injury
Acute glomerulonephritis
Urinary tract obstruction and reflux
Bilateral renal artery occlusion (thromboses or
emboli)
Kidney trauma
Cholesterol emboli
Post ESWL , etc

Chronic renal disease

Nondiabetic chronic renal disease
Diabetic nephropathy
Renal Parenchymal Disease
Chronic renal diseases that results from conditions
such diffuse atherosclerosis of the very small renal
arteries and diabetic nephropathy commonly
causes a higher incidence of hypertension than is
seen in a normal population of the same age.
Whatever initiates hypertension, when it is severe
enough, it can acutely damage the kidney
parenchymal cells, including the arterioles and the
juxtaglomerular apparatus vicious cycle of
events that includes sodium retention, worsening
hypertension and excessive release of renin
 Etiologi of Hypertension in
Chronic Kidney Disease

Extracellular volume overload

Incerased renin-angiotensin-aldosterone
system activity
Increased sympathetic nervous system activity
Endothelial cell dysfunction
Increased endothelin-1 release
Accumulation of asymmetric dimethylarginine
Decreased production of nitric oxide
Oxidative stress
Increased vasopressin release
Hypertensinogenic drugs (erythropoietin)
Coffman TM, Schriers Diseases of The
Kidney, 2013
Coffman TM, Schriers Diseases of The
Kidney, 2013
Risk Factors for Secondary Hypertension

Poor response to therapy (resistant)

Worsening of control in previously stable
hypertensive patients
Stage 3 hypertension ESH (SBP>180 or DBP>110)
Onset younger than age 20 or older than age 50
Significant hypertensive target organ damage
Lack of family history of hypertension
Findings on history, physical examination, or
laboratory testing suggesting a secondary
hypertension
Treatments
Based on underlying disease
 Drugs that Raises Blood
Pressure
Immunosuppressive agents Minerocorticosteroids
Cyclosporine, tacrolimus, Fludrocortisone
corticosteroid Antiparkinsonian
NSAID Bromocriptine
Ibuprofen, naproxen,
Monoamine oxidase
piroxicam inhibitors
COX-2 inhibitors Phenelzine
Celecoxib, rofecoxib,
Anabolic steroids
valdecoxib
Testosterone
Estrogens
Sympathomimetics
Weight-loss agents pseudoephedrine
Sibutramine, phentermine,
ephedrine
Stimulants
Nicotine, amphetamines
Conclusions
Remember clinical/diagnostic features of
common forms of secondary HTN
Important to appropriately screen prior
to suspected of having potentially
correctable causes of HTN
Understand limitations of
screening/treatment (atherosclerotic
RAS)
Renal Hypertension was the major cause
of secondary hypertension
Reference
1. Lyerly KM, Goodfriend TL. Secondary hypertension.
In: Moorthy AV, Becker BN, Boehm III FJ, Djamali A.
Pathophysiology of Kidney Disease and
Hypertension. Philadelphia. Saunders Elsevier. 2009.
p.197-208.
2. Kaplan NM. Kaplans Clinical Hypertension.
Philadelphia.Walters Kluwer, Lippincot Williams &
Wilkins. 10th Ed. 2010.p 288-338.
3. William J.Elliott,William F.Young Jr.Secondary
hypertension.In Henry R.Black,William
J.Elliott.Hypertension A companion to Braunwalds
Heart Disease.Philadelphia.Saunders Elsevier.2013
p.69-88.
4. Granger, JP and George EM. Role of the Kidneys in
Hipertension. In: Coffman, TM, Molitorus, BA, Falk RJ,
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