Diagnosis of Secondary Hypertension

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Diagnosis of Secondary Hypertension

• Morris Brown
• University of Cambridge

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Apparent Prevalence of Secondary Hypertension
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Apparent Prevalence of Secondary Hypertension
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Measure plasma renin
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Measure plasma renin
High (gt400 mU/L)
Low (lt10 mU/L)
? Renal Artery Stenosis
? Conns Syndrome
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Measure plasma renin
High (gt100 mU/L)
Low (lt20 mU/L)
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Causes of secondary hypertension

• Reversible
• Irreversible

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Causes of secondary hypertension

• Reversible
• Renal
• Endocrine
• Vascular
• Iatrogenic/toxic
• Irreversible
• Renal
• Monogenic syndromes

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Causes of secondary hypertension

• Reversible
• Renal
• Endocrine
• Vascular
• Iatrogenic/toxic
• Irreversible
• Renal
• Monogenic syndromes

• Renal artery stenosis
• Small pyelonephritic kidney
• Large hydronephrotic kidney
• Renin secreting tumor

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Causes of secondary hypertension

• Reversible
• Renal
• Endocrine
• Vascular
• Iatrogenic/toxic
• Irreversible
• Renal
• Monogenic syndromes

• Adrenal
• Conns
• Phaeochromocytoma

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Causes of secondary hypertension

• Reversible
• Renal
• Endocrine
• Vascular
• Iatrogenic/toxic
• Irreversible
• Renal
• Monogenic syndromes

• Co-arctation
• Vasculitis
• Takayasu
• Polyarteritis
• Scleroderma

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Causes of secondary hypertension

• Reversible
• Renal
• Endocrine
• Vascular
• Iatrogenic/toxic
• Irreversible
• Renal
• Monogenic syndromes

• Drugs
• Glucocorticoids
• NSAIDs
• Decongestants
• Liquorice
• Alcohol

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Causes of secondary hypertension

• Reversible
• Renal
• Endocrine
• Vascular
• Iatrogenic/toxic
• Irreversible
• Renal
• Monogenic syndromes

• Chronic Renal Failure
• Polycystic kidneys

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Poiseuilles Law and Hypertension
BP Peripheral Resistance x Cardiac Output
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Poiseuilles Law and Hypertension
BP Peripheral Resistance x Cardiac Output
Renin
Aldosterone
Angiotensin II (AII)


BP



N
A
Na
or
drenaline
Volume
Vasoconstriction
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Two types of hypertension type 1 (high-renin)
arteries
Angiotensinogen
AI
AII
Renin
adrenal glands
Aldosterone
kidneys
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Two types of hypertension type 2 (low-renin)
arteries
Angiotensinogen
AI
AII
Renin
adrenal glands
Aldosterone
kidneys
Na
Na
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Two types of drugs for hypertension 1Brown MJ.
Matching the right drug to the right patient.
Heart 200186113-120.
arteries
Angiotensinogen
AI
AII
Renin
adrenal glands
Aldosterone
kidneys
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Two types of drugs for hypertension 2Brown MJ.
Matching the right drug to the right patient.
Heart 200186113-120.
arteries
Angiotensinogen
AI
AII
Renin
adrenal glands
Aldosterone
kidneys
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Two types of drugs for hypertensionBrown MJ.
Matching the right drug to the right patient.
Heart 200186113-120.
arteries
Angiotensinogen
AI
AII
Renin
adrenal glands
Aldosterone
kidneys
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Principal pathways and disorders altering sodium
reabsorption in the nephron
Monogenic Syndromes of Hypertension are due to
molecular variants of the Na channels inhibited
by the diuretics
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Principal pathways and disorders altering sodium
reabsorption in the nephron
Monogenic Syndromes of Hypertension are due to
molecular variants of the Na channels inhibited
by the diuretics
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Principal pathways and disorders altering sodium
reabsorption in the nephron
Monogenic Syndromes of Hypertension are due to
molecular variants of the Na channels inhibited
by the diuretics
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Monogenic and secondary syndromes of
hypertension individual response to treatment
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Monogenic and secondary syndromes of
hypertension individual response to treatment
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Monogenic and secondary syndromes of
hypertension individual response to treatment
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Investigations for secondary hypertension

• Screening (i.e. all patients)
• Plasma electrolytes
• Plasma renin
• 24-h urine VMA (or other index of catecholamine
  secretion)

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Investigations for secondary hypertension

• Screening (i.e. all patients)
• Plasma electrolytes
• Plasma renin
• 24-h urine VMA (or other index of catecholamine
  secretion)
• Specialised
• Renal
• Vascular

• MAG3 Scan
• Angiography (MR/CT) MRI/CT Scan
• (Renal vein sampling)

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MAG3 Renogram
Pre-Captopril
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MAG3 Renogram
Pre-Captopril
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MAG3 Renogram
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3-D CT- and conventional angiogram 23 year old
accelerated hypertension
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Renal Vein Sampling for ReninRenin (Random)
9-56 mU/L
IVC Suprarenal 307
Aorta 287
LRV 522
RRV 259
IVC Infrarenal 242
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MR angiogram
22 year old man BP 160/120 mmHg on atenolol
lisinopril Creatinine 110 umol/L Renin 23mU/l
(9-56) on Atenolol, 578mU/l on Candesartan
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MR angiogram, suprarenal aortic stenosis
37 year old woman BP 210/52 mm Hg on 5
drugs Diffuse bruit front back Plasma renin
257 mU/L (5 x ULN) - repeated
off ?B 4672
182/57
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Renin-secreting tumour
WATANABE et al. Juxtaglomerular cell tumor.
International Journal of Urology  9 (12), 704-706
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Polycystic kidneys
Polycystic kidneys
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Investigations for secondary hypertension

• Screening (i.e. all patients)
• Plasma electrolytes
• Plasma renin
• 24-h urine VMA (or other index of catecholamine
  secretion)
• Specialised
• Adrenal
• Conns tumour

• Plasma aldosterone
• MRI/CT Scan
• Adrenal vein sampling

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Coronal MRI Scan of Conns Tumour
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CT Scan of Conns Tumour
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CT Scan of Conns Tumour
Untreated
Amlodipine
Spironolactone
Adrenalectomy
Brown Hopper. Calcium-channel blockade can mask
the diagnosis of Conn's syndrome. Postgrad Med J
199975235-6.
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Selective adrenal vein sampling
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Selective adrenal vein sampling
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Influence of AB drugs on plasma renin
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Influence of AB drugs on plasma renin
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Investigations for secondary hypertension

• Screening (i.e. all patients)
• Plasma electrolytes
• Plasma renin
• 24-h urine VMA (or other index of catecholamine
  secretion)
• Specialised
• Adrenal
• Phaeochromocytoma

• Plasma catecholamines
• MRI/CT Scan
• MIBG Scan
• Selective venous sampling

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Adrenal phaeochromocytomaCT and 123I-mIBG scans
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More phaeos
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