继发性高血压诊断及治疗的新进展

近年来广大医务工作者对高血压进行的大量研究工作,使得继发性高血压的鉴别诊断以及药物治疗方面取得不少进展,现简介如下。一、继发性高血压的鉴别诊断1.肾动脉狭窄性高血压的诊断:肾动脉狭窄或阻塞造成的高血压,肾素—醛固酮—血管紧张素系统起主要作用。肾动脉狭窄时,狭窄的远端压力下降,入球小动脉压力随之下降,于是刺激近球旁装置释放肾素,从而引起一系列内分泌改变造成血压升高。所以任何因素导致肾动脉压力下降,均可刺激肾素释放。目前临床诊断单侧肾动脉狭窄,除作肾动脉造影外,还应作分侧肾静脉血浆肾素活性(PRA)测定,来     

肾血管性高血压筛选诊断方法的探讨

为了对肾血管性高血压病人作出准确无误诊断.自1978年～1991年我们通过采用双肾B型超声,双肾同位素肾图、肾盂分泌造影、肾动脉造影和分肾静脉肾素活性测定对70例肾血管性高血压病人进行了检查。结果证明双肾B超声检查对肾血管性高血压诊断率为62％;肾盂分泌造影检查的诊断率为83％;双肾同位素肾图的诊断率为79％;肾动脉造影的阳性诊断率为100％;肾静脉肾素活性测定对肾动脉狭窄的功能性诊断达100％。     

肾静脉肾素水平与肾动脉介入治疗疗效的相关性研究

目的探讨肾静脉肾素活性,血浆内皮素(ET)、一氧化氮(NO)、钙素基因相关肽(CGRP)水平对肾动脉狭窄介入治疗疗效的预测价值。方法60例冠心病合并高血压患者经肾动脉造影,证实为肾动脉狭窄,予肾动脉支架植入术;测定所有病例介入治疗前后的肾静脉肾素活性和血浆ET、NO、CGRP水平。并对病人的血压进行2年随访。结果60例患者根据术前肾素水平分为肾素比值(RVRR)>1.5组和RVRR<1.5组。所有患者肾动脉狭窄侧肾静脉肾素活性高于对侧[(3.89±3.14)nmol/L/h和(2.01±1.93)nmol/L/h,P<0.05],介入治疗后患侧肾静脉肾素浓度明显下降,RVRR>1.5组低于RVRR<1.5组[(1.92±2.15)nmol/L/h和(2.42±0.56)nmol/L/h,P<0.05],血浆ET和NO水平与RVRR<1.5组相比有统计学差异(P<0.05),术后血压明显下降,血压有效率75.68%,与RVRR<1.5组比P<0.05。结论测定肾静脉肾素活性,血浆ET、NO的水平对肾动脉血管成形术近期疗效有预测价值。     

经导管选择性静脉采血技术对肾血管性及异体肾移植术后高血压的应用

采用选择性静脉导管分段取血对10例肾血管性和3例异体肾移植术后高血压病人测定肾素活性水平,比较左右肾静脉和下腔静脉肾素活性的比值,判定肾动脉狭窄取得了满意的结果。异体肾移植术后高血压患者行分测移植肾和自体病肾静脉血肾素活性,发现自体病肾静脉血肾素活性明显高于移植肾,动脉造影证明移植肾动脉无狭窄。为病肾肾素依赖性高血压。用无水乙醇枪塞自体病肾动脉,结果有效。     

血浆肾素活性测定对肾血管性高血压诊断价值的临床观察

自1986年以来,我们曾对10例非高血压病人和5例肾血管性高血压病人的周围循环血浆肾素活性及分肾静脉不同时间的血浆肾素活性进行了测定。周围血浆肾素活性及分肾静脉肾素活性对肾血管性高血压的诊断和预后以及肾素分泌的时间差别对临床诊断的意义进行了初步评价。     

肾动脉狭窄的X线诊断

本文报导了肾动脉狭窄的临床特点,腹主动脉造影的方法和X线表现,静脉尿路造影的X线表现及静脉尿路造影对提示肾动脉狭窄有意义的X线征象,但确定诊断则有赖于肾动脉造影。     

用带气囊导管(扩张)法治疗肾动脉狭窄

<正> 过去1年半时间内,少数医生用带气囊导管法(经皮肤穿刺经血管腔动脉成型术,简称PTA)治疗了近200例继发于动脉粥样硬化的肾动脉狭窄病人。他们的原始材料表明,本法很容易取得和手术治疗相同的效果。方法:术前准备:作肾动脉造影,明确诊断;作双侧肾静脉血浆肾素活性测定。扩张日上述检查重复一次,以作比较。     

肾素—血管紧张素的生理(二)

(二)肾素-血管紧张素活动增强及其他机理有许多因素和条件可以影响肾脏分泌肾素:在妇女妊娠期血浆肾素活性(ARP)增高,月经周期的黄体期,由于孕酮的作用,血浆肾素活性也增强,口服避孕药也有同样的作用。ACTH,前列腺素(PGE)能刺激肾素分泌,这种作用受体内的离子负荷影响;正常人食物中K~ 过多可使血浆肾素活性下降,而缺钾则使肾素活性增强;在肾动脉内注入含高钾的溶     

外伤性肾动脉栓塞的影像学诊断

报告7例肾动脉损伤的影像学检查方法及其表现:静脉法尿路造影可见单侧肾脏不显影;CT扫描无增强效应,但有包膜下增强环及髓质内增强带;动态CT扫描或肾动脉造影可见肾动脉突然截断。     

老年肾血管性高血压的临床分析

肾血管性高血压由于肾动脉狭窄 ,使肾血流量减少 ,肾素 -血管紧张素 -醛固酮系统激活所引起的血压增高 ,是继发性高血压的常见发病原因。严重的肾动脉狭窄可以导致进行性肾损害 ,甚至肾功能丧失[1] 。因此 ,早期在高危人群中筛选出肾动脉病变具有重要的临床意义。1　对象与方法1.1　一般资料本院在 1997年 4月至 2 0 0 2年 5月期间 ,行冠状动脉造影的高血压患者常规行选择性肾动脉造影 ,在 30例患者中发现有 38支肾动脉狭窄。男性 2 2例 ,女性 8例 ,年龄 5 2岁～ 83岁 ,平均年龄 6 8.9岁± 9.4岁 ,6 5岁以上患者 2 6例 ,高血压病程 1a～ 30a…     

Renal vein plasma adenosine 3'',5''-cyclic monophosphate in renovascular hypertension.

The concentration of plasma adenosine 3',5'-cyclic monophosphate (cyclic AMP) and plasma renin activity (PRA) were measured concomitantly in blood from both renal veins and in arterial blood in 22 hypertensive patients. In the nine patients with true renovascular hypertension the concentration of plasma cyclic AMP was greater in the venous effluent of the kidney affected by the renal artery stenosis than in that of the unaffected or less affected kidney. The arteriovenous difference in cyclic AMP concentration was less on the affected side in all but one patient. The arteriovenous differences in PRA identified the affected kidney as the source of hyper-reninemia and showed that renin release from the other kidney was suppressed. In the 13 patients with hypertension associated with but unrelated to renal artery stenosis there were no consistent patterns of cyclic AMP concentration or PRA in the venous effluent of the kidneys or of their arteriovenous differences. In renovascular hypertension the venous effluent of the kidney affected by renal artery stenosis contains not only more renin but also more cyclic AMP, owing to either increased cyclic AMP production or decreased excretion or extraction of cyclic AMP by the affected kidney. This unilateral increase in cyclic AMP concentration may become a complementary diagnostic feature of true renovascular hypertension.     

The Angiotensin Infusion Test and Peripheral Venous Renin Activity

Forty hypertensive patients were studied to examine the assumption that the angiotensin pressor dose reflects endogenous renin activity. Peripheral renin activity was assayed by the method of Boucher et al.⁴ Sensitivity to the infusion of synthetic angiotensin II was determined as suggested by Kaplan and Silah.¹

Sixteen patients with essential hypertension with normal renal angiography required 3.8 ng. angiotensin/kg./min. to raise the diastolic pressure 20 mm. Hg. All but one were sensitive to angiotensin infusion of less than 5 ng./kg./min. Renin activity was normal in all except in one sensitive subject. Angiotensin infusion response and mean renin activity in 13 patients with essential hypertension with abnormal renal angiography were similar to that of the first group. The pressor dose in 11 renovascular hypertensives was 9.8 ng./kg./min. All but three had elevated plasma renin activity.

Our results suggest that: (1) the angiotensin infusion test is suitable for differentiating patients with true renovascular hypertension from those with essential hypertension with or without associated renal artery disease; (2) the angiotensin pressor dose correlates with the level of peripheral venous renin activity (p < 0.01).

     

Pheochromocytoma presenting with pulmonary edema and hyperamylasemia.

A 28-year-old woman was admitted to hospital with acute pulmonary edema, mild abdominal discomfort and hyperamylasemia. From the 2nd hospital day hypertensive episodes occurred daily. The furosemide screening test for renovascular hypertension revealed elevated plasma renin activity (PRA) but an intravenous pyelogram revealed a right suprarenal mass and no evidence of renovascular compression. Elevated values of plasma and urinary catecholamines indicated a pheochromocytoma, and a single chromaffin tumour was resected. It is important to monitor left ventricular filling pressure during operative removal of a pheochromocytoma. Postoperatively the patient had normal blood pressure and PRA. Decreased urinary amylase clearance and abnormal pancreatic and salivary amylase isoenzymes were found.     

Experimental model of renovascular hypertension.

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Renal artery digital-subtraction angiography. An outpatient investigation for renovascular hypertension

The adequacy and convenience of the digital-subtraction angiographic procedure by means of a Diasonics DF100 as an investigation in renovascular disease were assessed over a nine-month period in 82 sequential renal artery studies, of which 76 were carried out in patients referred for the investigation of hypertension. Contrast medium was injected as a bolus by way of a centrally placed venous catheter, or a small (5 French size or smaller) arterial catheter. Patients tolerated the procedure well, and were fully mobile within 10 minutes to one hour (venous injection) and within two hours (arterial injection) after the procedure. Of the 82 studies, nine were judged as inadequate. All technical failures occurred with the venous injection technique. Of the 76 patients with hypertension, the main renal artery was judged as normal in 61. Renal artery lesions were demonstrated in 15 studies (13 patients). Renal vein renin studies, and the clinical or postoperative course supported the diagnosis of renovascular hypertension in 11 of these. Digital-subtraction angiography of the renal artery is a useful investigation in suspected renovascular hypertension. Its major advantage over conventional angiography is that it can be performed on an outpatient basis.     

Renin profiling for diagnosis and treatment of hypertension.

Recent research shows that the renin-angiotensin-aldosterone axis either maintains or causes some or all of the high blood pressure of most patients and demonstrates anew that renin-sodium profiling defines this involvement. Performed with a serum potassium measurement, this now reliable test is useful for primary screening and then, in conjunction with renal vein renin studies or an aldosterone profile, for diagnosis or exclusion of surgically curable renovascular or adrenocortical hypertensions. For the remaining majority with essential hypertension, renin profiling exposes the relative participation of either vasoconstriction or volume factors, thereby guiding simpler, more specific, and predictably effective antirenin or antivolume treatments. Renin profiling identifies those in whom treatment should begin with a beta-blocker as opposed to a diuretic while not infrequently also providing baseline information about severity and prognosis in individual patients.     

Digital vascular imaging and selective renin sampling in evaluation of vascular anatomy in renal transplant recipients

Sixty-five renal transplant recipients underwent digital vascular imaging of the graft and simultaneous selective venous sampling for plasma renin activity. Renal artery stenosis was found in seven patients but did not appear to be functionally important. Diffuse intrarenal arterial attenuation was found in seven patients and was associated with impaired graft function and perfusion; it may indicate chronic rejection. Lower pole hypoperfusion was found in nine patients without impaired graft function or perfusion; its clinical relevance is uncertain. Aneurysmal dilatation of the main renal artery was found in two patients. Severe hypertension was common in patients with these three major abnormalities, but a causal association between the abnormality and hypertension could rarely be inferred. It may be the abnormalities on digital vascular imaging, especially diffuse intrarenal arterial attenuation and lower pole hypoperfusion, are secondary to severe hypertension. Digital vascular imaging with simultaneous selective venous sampling for plasma renin activity is useful in evaluating the vascular anatomy of the grafted kidney and in assessing any abnormality found. The combined procedure was well tolerated by all patients with no complications and no incidence of acute tubular dysfunction or proteinuria after the investigation.     

Role of nephrectomy in hypertension with renal artery occlusion.

Nephrectomy was performed in 12 patients with complete renal artery occlusion and hypertension refractory to intensive medical therapy. Renal vein renin was assayed preoperatively in 10 of the 12, and in 8 the ratio was at least 1.5:1, strongly suggesting renal artery occlusion on the side with the higher concentration of renin in venous blood. In two patients peripheral plasma renin activity was very high before operation, then decreased greatly afterwards. Three patients were considered cured and eight improved (overall improvement rate, 92%). The results were predicted by the renin ratio.     

Predictive value of renin determinations in renal artery stenosis

The prognostic value of renal vein and peripheral renin levels was analyzed in 66 patients with unilateral renal artery stenosis who underwent corrective surgery. Patient selection for operation was independent of renin results. Fifty-three percent of those with confirmed renovascular hypertension had renal vein renin ratios less than 2.0, ie, within the 95% confidence limit for the control group of 82 patients with essential hypertension. Thirty-four patients with clearly lateralizing renin data (ipsilateral:contralateral greater than or equal to 1.5 and contralateral:peripheral less than or equal to 1.3) were benefited by operation, but 23 additional patients with nonlateralizing data also benefited. No proposed scheme for renin data analysis detected more than 75% of those with renovascular hypertension. Although lateralizing renin data are highly predictive of operative benefit, nonlateralizing data do not necessarily herald operative failure and should not be dogmatically used to exclude surgical intervention.