KIDNEY & HYPERTENTION 1 Dr. Ruba Nashawati

Kidney Hypertension 2

How Does Kidney Cause Hypertension? 3

Renal Parenchymal Disease Renovascular HTN 4

Renal Parenchymal Disease 5

Common cause of Secondary HTN Every Parenchymal Kidney Disease May Resolve With original Disease Treatment 6

Multifactorial cause Disturbances: Na/water balance K balance Ca balance vasodepressors/prostaglandins 7

Renovascular HTN 8

BP Syndrome of BP (Systolic/Diastolic) Kidney Arterial Circulation produced by a variety of conditions with Kidney Arterial Circulation 9

Two Main Causes 10

ASRVD ATHEROSCLEROSIS 75-90% ( more common in OLDER patients) 11

FMD FIBROMUSCULAR DYSPLASIA 10-25% (More Common In Young Patients, Females ) 12

Others 1.Aortic/Renal Dissection 2.Takayasu’s Arteritis 3.Thrombotic/Cholesterol Emboli 4.Post Transplantation Stenosis 5.Post Radiation 13

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FIBROMUSCULAR DYSPLASIA 16

Non-Atherosclerotic Arteriopathies Distal Vessel Beyond 1 st 2 cm From Aorta Large & Medium-sized Renal Arteries 17

Females Young Females Early Onset HTN years Asymptomatic  many years Both Both Renal Arteries 18

Three Main Types: 1.Medial 1.Medial Fibroplasia,Most Common Intimal 2. Intimal Fibroplasia 3.Periadvential 3.Periadvential Fibroplasia 19

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Atherosclerotic Renovascular Disease 21

Common most Common cause of RVH 50 >50 years systemic + systemic Atherosclerosis ESRD Can cause ESRD 1 st 2 nd 1 st or 2 nd cm of Renal Artery 22

PATHOPHYSIOLOGY 23

24 luminal occlusion 70-80% 70-80% RVH

25  poststenotic P 10-20%(aortic P) plasma Renin Activation

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Features of Renovascular Hypertension 29

Activation Of (RAS) Early Paroxysmal Symptoms: Sympathetic Nervous System Activation abnormal Circadian Rhythm: Loss Of Nocturnal Pressure Fall 30

Accelerated Target Organ Damage Left Ventricular Hypertrophy Microvascular Disease Renal Injury: Fibrosis 31

Clinical Feature 32

33 Clinical Feature Essential HTN% Renovascular HTN% Duration <1 Year1224 Age Of Onset >50 Years 915 Family History Of HTN 7146 Grade 3 Or 4 Fundi715 Abdominal Bruit946 BUN>20mg/dl816 K < 3.4 Meq/L816 Urinary Casts920 Proteinuria3246

Syndromes Associated with Renovascular Hypertension 34

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Early Or Late Onset HTN ( 50) Early Or Late Onset HTN ( 50) Acceleration Of Treated Essential HTN Acceleration Of Treated Essential HTN Deterioration Of Renal Function In Treated Essential Hypertension Deterioration Of Renal Function In Treated Essential Hypertension ARF During Treatment Of HTN ARF During Treatment Of HTN 36

Flash Pulmonary Edema Flash Pulmonary Edema Progressive Renal Failure Progressive Renal Failure Refractory Congestive Cardiac Failure Refractory Congestive Cardiac Failure 37

Diagnosis 38

Goals of Diagnostic Evaluation Establishing: Unilateral Or Bilateral Stenosis Or Stenosis To A Solitary Kidney) Presence And Function Of Stenotic And Nonstenotic Kidneys 39

Goals of Diagnostic Evaluation Establishing: Hemodynamic Severity Of Renal Arterial Disease Plan Vascular Intervention: Degree & Location of Atherosclerotic disease 40

scan Nuclear Renal scan Renal Artery Duplex Ultrasonography CT Angiography (MRA) 41

CONVENTIONAL ANGIOGRAPHY STANDARD 42

Therapy 43

Goals of Therapy Improved Blood Pressure Control A. Prevent Morbidity & Mortality B. Reduce Medication Requirement 44

Goals of Therapy 45 Preservation Of Renal Function  Episodes Of Circulatory Congestion (Flash Pulmonary Edema)  Risk Of Progressive Vascular Occlusion  Loss Of Renal Function

Ischemic Nephropathy Azotemic Renovascular Disease Loss Of Renal Function Beyond An Arterial Stenosis Due To Impaired Renal Blood Flow 46

Medical Therapy 47

Modifiable Cardiovascular Risk Factors weight loss smoking cessation low-dose aspirin 48

Statin Therapy. BP Control Target < 140/90 mm Hg + CKD/Diabetes < 130/80 mm Hg 49

Renal Revascularization 50

Percutaneous Transluminal Renal Fibromuscular Dysplasia Angioplasty and Stenting 51

52 FMD + Long Aneurysmal > 1.5 Cm Surgical Revascularization

Atherosclerotic Disease: Endovascular Stents 53

54 Refractory To Medical Therapy Surgical Revascularization

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HTN in Kidney Transplantation Same As Native Kidney Immunosuppressive Drugs Graft Artery Stenosis 56

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HTN Causes Kidney Diseases &Vice Versa Good Control Of HTN Prevent Kidney Disease 58

Don’t Hesitate To Contact Nephrologist When Cr >1 mg/dl 59

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