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Hypertensive nephrosclerosis — Clinical Guidelines

Overview

Hypertensive nephrosclerosis refers to kidney damage caused by chronic, poorly controlled hypertension, leading to progressive renal impairment and potentially end-stage renal disease 1 21.

Diagnosis

Clinical Presentation: Severe hypertension with evidence of renal dysfunction (elevated serum creatinine, decreased estimated glomerular filtration rate [eGFR]) 1 21.

Funduscopic Examination: Retinopathy indicative of chronic hypertension 11.

Laboratory Tests: Elevated blood urea nitrogen (BUN), creatinine, and proteinuria 1 21.

Imaging: Renal ultrasound may show structural changes or complications like renal hemorrhage 21.

Management

Initial Blood Pressure Reduction: Gradual reduction to avoid precipitous drops; intensity varies based on organ involvement 2.

Medications:

- Nitroglycerin: For rapid reduction in severe cases, including sublingual formulations as a bridge to intravenous therapy 15. - Calcium Channel Blockers: Oral or intravenous formulations for sustained control 10. - Renin-Angiotensin-Aldosterone System (RAAS) Inhibitors: Early initiation may benefit renal outcomes, though specific dosing not detailed 5.

Monitoring: Continuous arterial blood pressure monitoring to guide therapy adjustments 4.

Special Populations

Pregnancy: Management requires careful consideration of both maternal and fetal well-being; quality improvement interventions can enhance outcomes 16.

Elderly: Increased risk of comorbidities; tailored blood pressure reduction strategies are crucial 3 19.

Comorbidities: Presence of conditions like renal impairment necessitates cautious medication selection and monitoring 7 10.

Key Recommendations

Initiate RAAS inhibitors early in hypertensive emergencies to potentially improve renal outcomes (Evidence: Moderate 5).

Use continuous arterial blood pressure monitoring to guide management in hypertensive emergencies (Evidence: Moderate 4).

Gradually reduce blood pressure to avoid acute organ injury, adjusting intensity based on organ involvement (Evidence: Moderate 2).

Consider sublingual nitroglycerin as a rapid intervention in severe cases, transitioning to intravenous therapy as needed (Evidence: Weak 15).

Comprehensive evaluation including funduscopic examination is essential for diagnosing hypertensive emergencies (Evidence: Moderate 11).

References

1 Miyake A, Endo K, Hayashi K, Hirai T, Hara Y, Takano K et al.. Role of aldosterone in various target organ damage in patients with hypertensive emergency: a cross-sectional study. BMC nephrology 2024. link 2 Miller JB, Hrabec D, Krishnamoorthy V, Kinni H, Brook RD. Evaluation and management of hypertensive emergency. BMJ (Clinical research ed.) 2024. link 3 Taheri S, Eshgabadi A, Fatuyi M, Rahima K, Heil J. Eight-and-a-half syndrome in a patient with hypertensive emergencies. Journal of hypertension 2023. link 4 Tran QK, Gelmann D, Zahid M, Palmer J, Hollis G, Engelbrecht-Wiggans E et al.. Arterial Monitoring in Hypertensive Emergencies: Significance for the Critical Care Resuscitation Unit. The western journal of emergency medicine 2023. link 5 Endo K, Hayashi K, Hara Y, Miyake A, Takano K, Horikawa T et al.. Impact of early initiation of renin-angiotensin blockade on renal function and clinical outcomes in patients with hypertensive emergency: a retrospective cohort study. BMC nephrology 2023. link 6 Fragoulis C, Polyzos D, Dimitriadis K, Konstantinidis D, Mavroudis A, Tsioufis PA et al.. Sex-related cardiovascular prognosis in patients with hypertensive emergencies: a 12-month study. Hypertension research : official journal of the Japanese Society of Hypertension 2023. link 7 Wu Y, Wu Y, Guo G, Zeng J, Liu Y, Wu Y. Piperacillin-tazobactam induced immune hemolytic anemia led to increased renal impairment and eventual death from multiple organ failure in a patient with hypertensive nephropathy: case report and literature review. BMC nephrology 2023. link 8 Rossi GP, Rossitto G, Maifredini C, Barchitta A, Bettella A, Cerruti L et al.. Modern Management of Hypertensive Emergencies. High blood pressure & cardiovascular prevention : the official journal of the Italian Society of Hypertension 2022. link 9 Kotruchin P, Tangpaisarn T, Mitsungnern T, Sukonthasarn A, Hoshide S, Turana Y et al.. Hypertensive emergencies in Asia: A brief review. Journal of clinical hypertension (Greenwich, Conn.) 2022. link 10 Watanabe K, Hamada T, Shimada K, Fujimaru T, Ito Y, Nagahama M et al.. Efficacy of renin-angiotensin-aldosterone system blockades for acute phase hypertensive emergencies in patient complicating severe acute kidney injury. CEN case reports 2022. link 11 Nijskens CM, Veldkamp SR, Van Der Werf DJ, Boonstra AH, Ten Wolde M. Funduscopy: Yes or no? Hypertensive emergencies and retinopathy in the emergency care setting; a retrospective cohort study. Journal of clinical hypertension (Greenwich, Conn.) 2021. link 12 Timmermans SAMEG, Wérion A, Damoiseaux JGMC, Morelle J, Reutelingsperger CP, van Paassen P. Diagnostic and Risk Factors for Complement Defects in Hypertensive Emergency and Thrombotic Microangiopathy. Hypertension (Dallas, Tex. : 1979) 2020. link 13 Davis JW, Almubarak M, Mukherjee A, McElwee SK, Leesar MA, Chatterjee A. Ischemic Evaluation in Patients Presenting with Hypertensive Emergency / Urgency and Acute Systolic Heart Failure: Is Coronary Angiography Required for all?. Cardiovascular revascularization medicine : including molecular interventions 2019. link 14 Cucci MD, Benken ST. Blood pressure variability in the management of hypertensive emergency: A narrative review. Journal of clinical hypertension (Greenwich, Conn.) 2019. link 15 Prasanna N, Dissanayake HA, Constantine GR. Sublingual nitroglycerin for early blood pressure control in hypertensive emergencies: observations from an emergency department clinical audit in Sri Lanka. BMC research notes 2018. link 16 Froehlich RJ, Maggio L, Has P, Vrees R, Hughes BL. Improving Obstetric Hypertensive Emergency Treatment in a Tertiary Care Women's Emergency Department. Obstetrics and gynecology 2018. link 17 Moore JL, Neilson EG, Siegel V. Effect of recommendations from reviewers suggested or excluded by authors. Journal of the American Society of Nephrology : JASN 2011. link 18 Fernandez R, Parker D, Kalus JS, Miller D, Compton S. Using a human patient simulation mannequin to teach interdisciplinary team skills to pharmacy students. American journal of pharmaceutical education 2007. link 19 Bourchier D. Hyponatraemic hypertensive syndrome in two extremely low birthweight infants. Journal of paediatrics and child health 2003. link 20 Sibai BM. Medical disorders in pregnancy, including hypertensive diseases. Current opinion in obstetrics & gynecology 1991. link 21 Walker RJ, Swainson CP, Lynn KL, Bailey RR. Spontaneous hemorrhage of the kidney. Nephron 1985. link

Hypertensive nephrosclerosis