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Boulestreau R, Śpiewak M, Januszewicz A, Kreutz R, Guzik TJ, Januszewicz M, Muiesan ML, Persu A, Sarafidis P, Volpe M, Zaleska-Żmijewska A, van den Born BJH, Messerli FH. Malignant Hypertension:A Systemic Cardiovascular Disease: JACC Review Topic of the Week. J Am Coll Cardiol 2024; 83:1688-1701. [PMID: 38658108 DOI: 10.1016/j.jacc.2024.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/30/2024] [Accepted: 02/05/2024] [Indexed: 04/26/2024]
Abstract
Malignant hypertension (MHT) is a hypertensive emergency with excessive blood pressure (BP) elevation and accelerated disease progression. MHT is characterized by acute microvascular damage and autoregulation failure affecting the retina, brain, heart, kidney, and vascular tree. BP must be lowered within hours to mitigate patient risk. Both absolute BP levels and the pace of BP rise determine risk of target-organ damage. Nonadherence to the antihypertensive regimen remains the most common cause for MHT, although antiangiogenic and immunosuppressant therapy can also trigger hypertensive emergencies. Depending on the clinical presentation, parenteral or oral therapy can be used to initiate BP lowering. Evidence-based outcome data are spotty or lacking in MHT. With effective treatment, the prognosis for MHT has improved; however, patients remain at high risk of adverse cardiovascular and kidney outcomes. In this review, we summarize current viewpoints on the epidemiology, pathogenesis, and management of MHT; highlight research gaps; and propose strategies to improve outcomes.
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Affiliation(s)
- Romain Boulestreau
- Université de Bordeaux, UMR Inserm 1034, Service des maladies coronaires et vasculaires, CHU de Bordeaux, INI-CRCT network, Pessac, France
| | - Mateusz Śpiewak
- Magnetic Resonance Unit, Department of Radiology, National Institute of Cardiology, Warsaw, Poland.
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Reinhold Kreutz
- Charité-Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Tomasz J Guzik
- Department of Medicine and Omicron Medical Genomics Laboratory, Jagiellonian University, Collegium Medicum, Kraków, Poland; Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Maria Lorenza Muiesan
- European Society of Hypertension (ESH) Excellence Center, Department of Clinical and Experimental Sciences, University of Brescia and ASST Spedali Civili, Brescia, Italy
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Pantelis Sarafidis
- 1st Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Massimo Volpe
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele, Rome, Italy
| | - Anna Zaleska-Żmijewska
- Department of Ophthalmology, Medical University of Warsaw, Warsaw, Poland; Ophthalmic Teaching Hospital, Warsaw, Poland
| | - Bert-Jan H van den Born
- Department of Public and Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; Department of Internal and Vascular Medicine, Amsterdam UMC, University of Amsterdam, Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Franz H Messerli
- Department of Cardiology and Biomedical Research, University Hospital Bern, University of Bern, Bern, Switzerland; Jagiellonian University Kraków, Poland.
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Hakroush S, Tampe D, Korsten P, Tampe B. Impact of the COVID-19 Pandemic on Kidney Diseases Requiring Renal Biopsy: A Single Center Observational Study. Front Physiol 2021; 12:649336. [PMID: 34305628 PMCID: PMC8297651 DOI: 10.3389/fphys.2021.649336] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/18/2021] [Indexed: 12/23/2022] Open
Abstract
Background The coronavirus disease-2019 (COVID-19) pandemic impacted healthcare services for kidney disease patients. Lockdown and social distancing were mandated worldwide, resulting in closure of medical services. The diagnosis of various kidney diseases may have been delayed during the COVID-19 pandemic because non-urgent tests and visits were postponed due to closure of medical services during the lockdown. Methods We here report the impact of the COVID-19 pandemic on a total number of 209 native kidney diseases requiring renal biopsy for diagnosis in a retrospective observational study from a tertiary hospital in Germany. Results The lockdown period in March and April 2020 primarily affected patients admitted to the normal medical ward with a compensatory increased rate of renal biopsies in the postlockdown phase. In addition, there was a shift toward more patients admitted with hemoglobinuria during the COVID-19 pandemic. This phenomenon of an increased number of patients with hemoglobinuria during the COVID-19 pandemic was specifically observed in a subgroup with hypertensive nephropathy requiring renal biopsy and associated with increased proteinuria, not attributed to the COVID-19 lockdown period itself. Conclusion To our knowledge, this is the first report of identifying a subpopulation susceptible to closure of medical services during the COVID-19 pandemic and diagnostic delay of specific kidney diseases. Therefore, the COVID-19 pandemic should be regarded as a risk factor especially in patients with diseases other than COVID-19 primarily admitted to the normal medical ward.
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Affiliation(s)
- Samy Hakroush
- Institute of Pathology, University Medical Center Göttingen, Göttingen, Germany
| | - Désirée Tampe
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
| | - Peter Korsten
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
| | - Björn Tampe
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
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Malignant hypertension: diagnosis, treatment and prognosis with experience from the Bordeaux cohort. J Hypertens 2020; 37:316-324. [PMID: 30160657 DOI: 10.1097/hjh.0000000000001913] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Malignant hypertension, the most severe form of hypertension, is defined by high blood pressure and acute ischemic organ damage. It has a worse prognosis than other forms of hypertension, especially in black patients. New tools to assess organ damage, especially that of the heart and brain, are now available and may contribute to a better evaluation of these patients. This report improves knowledge of the characteristics of involved organs to facilitate diagnosis and to evaluate the effectiveness of our treatment protocol. METHOD The Bordeaux registry, started in 1995, recruited 168 patients. In addition to evaluations of their eyes and kidneys, these patients had a systematic evaluation of their hearts with ECG and echocardiography and, since 2007, a systematic brain MRI. Blood pressure was lowered with a protocol based on blockers of the renin-angiotensin system started at a very low-dose with forced titration over 48 h. Only an oral route was used for antihypertensive medication. RESULTS Systematic MRIs found significant brain damage in 93% of patients. Heart involvement was highly prevalent: 82% had left ventricular mass more than 60 g/m, and 56% had systolic dysfunction (estimated by global longitudinal strain). Renal involvement and thrombotic microangiopathy were respectively present in 55 and 15% of patients. Median follow-up was 48 months. Renal survival at 5 years was 90.8%, similar to other studies. CONCLUSION Malignant hypertension is a systemic disease causing severe damage to the brain, heart, kidneys and eyes, even in absence of symptoms. Renin-angiotensin system blockers seem to be the cornerstone of treatment.
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Abstract
ZusammenfassungErhöhter Blutdruck bleibt eine Hauptursache von kardiovaskulären Erkrankungen, Behinderung und frühzeitiger Sterblichkeit in Österreich, wobei die Raten an Diagnose, Behandlung und Kontrolle auch in rezenten Studien suboptimal sind. Das Management von Bluthochdruck ist eine häufige Herausforderung für Ärztinnen und Ärzte vieler Fachrichtungen. In einem Versuch, diagnostische und therapeutische Strategien zu standardisieren und letztendlich die Rate an gut kontrollierten Hypertoniker/innen zu erhöhen und dadurch kardiovaskuläre Erkrankungen zu verhindern, haben 13 österreichische medizinische Fachgesellschaften die vorhandene Evidenz zur Prävention, Diagnose, Abklärung, Therapie und Konsequenzen erhöhten Blutdrucks gesichtet. Das hier vorgestellte Ergebnis ist der erste Österreichische Blutdruckkonsens. Die Autoren und die beteiligten Fachgesellschaften sind davon überzeugt, daß es einer gemeinsamen nationalen Anstrengung bedarf, die Blutdruck-assoziierte Morbidität und Mortalität in unserem Land zu verringern.
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Malignant hypertension: does this still exist? J Hum Hypertens 2019; 34:1-4. [DOI: 10.1038/s41371-019-0267-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/22/2019] [Accepted: 09/23/2019] [Indexed: 12/19/2022]
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Kuntz S, Boulestreau R, Rubin S, Cremer A, Gosse P. [Arterial hypertension with multiple organ damage: A new entity?]. Presse Med 2018; 47:811-816. [PMID: 30293851 DOI: 10.1016/j.lpm.2018.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 09/07/2018] [Accepted: 09/07/2018] [Indexed: 11/26/2022] Open
Abstract
Hypertensive emergency. Stable incidence for several decades or even increasing (under diagnosed). Early and specific management improves prognosis. Absence of eye damage or lack of access to fundus should not delay or prevent the diagnosis. Multi Organ Damage Hypertension: new definition for an old entity: unusual, sudden and persistent blood pressure rise without threshold and ocular involvement or involvement of at least 3 target organs among brain, heart, kidney or endothelial disease.
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Affiliation(s)
- Sophie Kuntz
- CHU de Bordeaux, hôpital Saint-André, 1, rue Jean-Burguet, 33000 Bordeaux, France.
| | | | - Sébastien Rubin
- CHU de Bordeaux, hôpital Pellegrin, service de néphrologie, place Amélie-Raba-Léon, 33076 Bordeaux, France
| | - Antoine Cremer
- CHU de Bordeaux, hôpital Saint-André, 1, rue Jean-Burguet, 33000 Bordeaux, France
| | - Philippe Gosse
- CHU de Bordeaux, hôpital Saint-André, 1, rue Jean-Burguet, 33000 Bordeaux, France
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Epoxyeicosatrienoic acid analog attenuates the development of malignant hypertension, but does not reverse it once established: a study in Cyp1a1-Ren-2 transgenic rats. J Hypertens 2017; 34:2008-25. [PMID: 27428043 DOI: 10.1097/hjh.0000000000001029] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE We evaluated the therapeutic effectiveness of a new, orally active epoxyeicosatrienoic acid analog (EET-A) in rats with angiotensin II (ANG II)-dependent malignant hypertension. METHODS Malignant hypertension was induced in Cyp1a1-Ren-2 transgenic rats by activation of the renin gene using indole-3-carbinol (I3C), a natural xenobiotic. EET-A treatment was started either simultaneously with I3C induction process (early treatment) or 10 days later during established hypertension (late treatment). Blood pressure (BP) (radiotelemetry), indices of renal and cardiac injury, and plasma and kidney levels of the components of the renin-angiotensin system (RAS) were determined. RESULTS In I3C-induced hypertensive rats, early EET-A treatment attenuated BP increase (to 175 ± 3 versus 193 ± 4 mmHg, P < 0.05, on day 13), reduced albuminuria (15 ± 1 versus 28 ± 2 mg/24 h, P < 0.05), and cardiac hypertrophy as compared with untreated I3C-induced rats. This was associated with suppression of plasma and kidney ANG II levels (48 ± 6 versus 106 ± 9 and 122 ± 19 versus 346 ± 11 fmol ml or g, respectively, P < 0.05) and increases in plasma and kidney angiotensin (1-7) concentrations (84 ± 9 versus 37 ± 6 and 199 ± 12 versus 68 ± 9 fmol/ml or g, respectively, P < 0.05). Remarkably, late EET-A treatment did not lower BP or improve renal and cardiac injury; indices of RAS activity were not affected. CONCLUSION The new, orally active EET-A attenuated the development of experimental ANG II-dependent malignant hypertension, likely via suppression of the hypertensiogenic axis and augmentation of the vasodilatory/natriuretic axis of RAS.
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From malignant hypertension to hypertension-MOD: a modern definition for an old but still dangerous emergency. J Hum Hypertens 2015; 30:463-6. [DOI: 10.1038/jhh.2015.112] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 08/16/2015] [Accepted: 10/14/2015] [Indexed: 11/08/2022]
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Microscopic Haematuria and Clinical Outcomes in Patients With Stage 3-5 Nondiabetic Chronic Kidney Disease. Sci Rep 2015; 5:15242. [PMID: 26472621 PMCID: PMC4607953 DOI: 10.1038/srep15242] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 09/17/2015] [Indexed: 01/10/2023] Open
Abstract
Microscopic haematuria is proposed as a prognostic factor for renal outcomes in patients with glomerulonephritis. However, the role of haematuria in patients with advanced chronic kidney disease (CKD) or heavy proteinuria has not been investigated. We divided 1799 patients with stage 3–5 nondiabetic CKD into 3 groups according to the results from 3 urinalyses: no haematuria (0–2 red blood cells [RBCs]/hpf ≥2 times), mild haematuria (2–5 RBCs/hpf ≥2 times) and moderate haematuria (≥5–10 RBCs/hpf ≥2 times). The estimated glomerular filtration rate was 25.4 mL/min/1.73 m2, with a urine protein-to-creatinine ratio (UPCR) of 881 mg/g. The hazard ratios (HRs) of mild and moderate haematuria for end-stage renal disease (ESRD) were 1.28 (95% confidence interval [CI]: 1.05–1.56, P = 0.024) and 1.34 (95% CI: 1.03–1.74, P = 0.030), respectively. The HR of moderate haematuria for mortality was 1.56 (95% CI: 1.11–2.20, P = 0.011). According to subgroup analysis, the HR of moderate haematuria for ESRD in patients with a UPCR of <500 mg/g was more prominent than that in patients with a UPCR of ≥500 mg/g. Microscopic haematuria in patients with stage 3–5 nondiabetic CKD is associated with increased risks of ESRD and mortality.
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