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The relationship of hypertensives and many pathological syndromes still remains unclear. A mathematical model in terms of the fluid mechanics and physicochemical analyses is established to correlate the plasma viscosity, the shear stress and the rate of shear in blood stream with the ligand-receptor dissociation constant. This model has arrived at the conclusive results that high viscosity, high rate of shear created in the blood streams, and the peripheral resistance may act as important preceding factors to induce a serial subsequent pathological clinical manifestations. High viscosity may interfere with the ligand-receptor combination, in contrast, high rate of shear may knock the ligand (s) off the existing ligand-receptor complex, while elevation of peripheral resistance may slow down the blood flow rate, resulting in a diminished dissociation of ligand-receptor complex. This model has successfully interpreted the possible cause of some post-hypertensive abnormal outcome manifestations involving obstructive and degenerative stenosis (such as renal artery stenosis), growth retardation, blood vessel detriment, coarctation of aorta, coronary thrombotics, atherosclerosis, hyperinsulinemia, diabetes, obesity, hypothyroidism, infertility, and at the worst, carcinoma, etc.
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PMID:Fluid mechanical and physicochemical modeling interprets hypertension to be capable of inducing secondary complications. 1714 24

Renal artery stenosis is a consequence of generalized atherosclerosis and many specialists perform routine selective renal angiography to detect and treat renal artery stenosis. The incidence of clinically important renal artery stenosis is not well defined in patients with symptomatic peripheral arterial disease. The purpose of this study was to better delineate the incidence of and the risk factors associated with renal artery stenosis, renovascular hypertension, and ischemic nephropathy incidentally discovered during angiography for symptomatic peripheral arterial disease. Two hundred consecutive patients undergoing angiographic evaluation of symptomatic lower extremity peripheral arterial disease were studied retrospectively. Angiograms were reviewed for the presence of renal artery stenosis (defined as >or= 25% diameter reduction in either renal artery) and findings were then correlated to the clinical diagnosis of renovascular hypertension (> 50% renal artery stenosis and >or= 3-drug resistive hypertension) and ischemic nephropathy (defined as > 50% bilateral renal artery stenosis, 3-drug hypertension, and creatinine >or= 1.5). Angiographic findings were also correlated with risk factors to determine if a relationship correlated to the presence of and degree of renal artery stenosis. Data were analyzed using the Student's t test, Chi-square model, and multiple logistic regression analysis. The overall incidence of any degree of renal artery stenosis in this study population was 26% (52 patients). Only 24 (12%) patients had an incidental finding of >or= 50% stenosis in either renal artery. Six (3%) of these patients were found to have associated renovascular hypertension. Additionally, 9 (4.5%) patients had coexistent renal insufficiency and significant renal artery stenosis; five with end-stage renal disease on chronic hemodialysis. Only one patient with end-stage renal disease had poorly controlled 3-drug hypertension. Thus definitive ischemic nephropathy was present in only one (0.5%) patient. Statistically significant risk factors associated with the presence of renal artery stenosis include hypertension (P < .001), coronary disease (P = .024), female gender (P = .010), diabetes (P = .039), aorto-iliac disease (P = .031), multiple levels of peripheral arterial disease (P < .001), and age over 60 ( P < .001). While the incidence of renal artery stenosis in patients being evaluated for symptomatic peripheral arterial disease is similar to that reported in the cardiology literature, the incidence of renovascular hypertension and ischemic nephropathy is exceedingly low (3% and 0.5%, respectively)-findings similar to data reported in the general hypertensive population. These data suggest that incidental selective renal angiography is not justified in patients with symptomatic peripheral arterial disease.
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PMID:Is incidental renal arteriography justified in a population of patients with symptomatic peripheral arterial disease? 1746 98

The renin-angiotensin-aldosterone system (RAAS) plays an important part in the pathogenesis of arterial hypertension and the complications it causes in organs (the heart, the circulatory system, the brain, the kidneys), heart failure and kidney diseases. Materials that block the most upstream point of the RAAS cascade (ACE inhibitors - ACEI, AT1,-receptor (AT1R) blockers, aldosterone receptor blockers) have greatly expanded our options in the treatment and primary and secondary prevention of cardiovascular and renal diseases. ACEI and AT1R blockers interrupt the normal feedback provided by the release of renin into the circulatory system from the kidneys. After they are applied the reactive increase in active circulating renin leads to increased creation of angiotensin I and angiotensin II and the subsequent return of aldosterone secretions to pre-treatment values ("escape" phenomenon). The possible negative effect of these intermediary products of an incomplete blockade of RAAS on organ complications lead to an effort to develop a material that could block the renin-angiotensin cascade at its first stage--i.e. a renin blocker. The first efforts with renin antibodies or peptide analogues of renin prosegments failed to satisify the basic requirements for long-term medication--effectiveness when used orally. In recent years the first non-peptidic, oral renin ihibitor providing sustained effects has been developed, aliskiren fumarate. Aliskiren reduces BP depending on the dose (50-300 mg/day) in monotherapy or in combination with hydrochlorothiazide. Aliskiren lowers plasma renin activity (PRA) and neutralises the activation of the RAAS triggered by hydrochlorothiazide. Ambulatory BP monitoring has shown that taking the medicine once a day has a 24-hour effect and its continued residence in the kidneys suggests renoprotective effects. The compound is in the third stage of clinical tests as a monotherapy or in combination for the treatment of hypertension. It has also been shown to have an influence on the regression of cardiac hypertrophy (Aliskiren in Left-Ventricular Hypertrophy trial - ALLAY), the treatment of heart failure (Aliskiren Observation of Heart Failure Treatment trial - ALOFT) and diabetic (Aliskiren in the Evaluation of Proteinuria in Diabetes trial - AVOID). In April 206, the FDA permitted the use of aliskiren in the USA for the treatment of high BP and it is currently undergoing testing in Europe. The renin inhibitor has minimal undesirable side effects, like AT1-receptor blockers. The slightly lower effectiveness ofaliskiren than AT1-receptor blockers in reducing BP is caused by the fact that it does not block bradykinins. It is recommended as a monotherapy for clinical use or in combination with other antihypertensive medicines for conditions with high levels of PRA including its rise after diuretics, ACEI and AT1-receptor blockers. Aliskiren could therefore be used primarily with young patients, Caucasians, persons with ACEI intolerance, and also in diseases where angiotensin II is involved in the pathogenesis and the secondary prevention of cardiovascular disease. It is also safe for persons with concurrent renal problems, because it is mainly removed by the liver without great interference with other materials. Like ACEI, the renin inhibitor has a vasodilatory effect which could potentially improve the elasticity of arteries. The medicine has the same limitations and contraindications as ACEI and AT1R blockers, such as pregnancy and bilateral renal artery stenosis. A definitive assessment of the benefit of this new class of medicines and its broad application in the treatment of cardiovascular and other diseases will require demonstration of its long-term effect on morbidity and mortality, as well as comparison with other RAAS blockers in long clinical studies, which represent research programmes lasting another 7 to 8 years.
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PMID:[Does the rennin inhibitor aliskiren offer promising novel opportunities in the treatment of cardiovascular diseases?]. 1757 67

Identification and treatment of hypertension should be an important focus of physicians caring for children. Ultimately, a link between hypertension in children and the risk of cardiovascular disease will be established. Further long-term studies are likely to show that morbidity and mortality will be decreased by the institution of treatment of hypertension in children. Additional risk factors such as obesity and lipid disorders should be sought and targeted for treatment as well. Lifestyle modifications are advised for all patients and can be tried solely for those with blood pressures between the 95th and 99th percentiles. Drug therapy is indicated in children with blood pressures greater than the 99th percentile, secondary hypertension, coexisting diabetes, left ventricular hypertrophy, or those who fail a trial of nonpharmacologic treatment. Children with white coat hypertension should not be treated with drugs. Children with renal artery stenosis and drug-refractory hypertension should be considered for percutaneous angioplasty or surgery depending on the anatomy of the lesion and operator experience. Children requiring multiple drug classes for control of blood pressure and older adolescents on one drug with renal artery lesions amenable to a percutaneous procedure may elect intervention in an attempt to reduce or eliminate drug therapy. Infants and children with hypertension due to native coarctation of the aorta should undergo surgical repair. Older children and adolescents with native coarctation should have surgical repair or percutaneous angioplasty/stenting. Hypertension secondary to recurrent coarctation is usually treated with a percutaneous intervention.
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PMID:Management of systemic hypertension in children and adolescents: an update. 1789 67

Hypertension in patients with renovascular disease poses a major clinical challenge. Renal arterial disease accelerates hypertension by activation of multiple pressor systems. Although younger individuals with fibromuscular lesions often respond well to angioplasty with minor associated risks, care must be taken in cases of complex vascular anomalies, such as renal artery aneurysms. More than 85% of patients referred for revascularization have atherosclerotic renal artery stenosis; most are older patients with preexisting hypertension, diabetes, and vascular disease. The benefits of stent revascularization in this group are controversial. Antihypertensive therapy works best with drugs that block the renin-angiotensin system; however, most patients require multiple agents. Detailed analysis of the literature and small prospective trials failed to identify major benefits with renal artery angioplasty as compared with intensive drug therapy. The CORAL study and others seek to randomly assign subjects with high-grade renovascular lesions to optimal medical management with and without stenting.
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PMID:Renovascular hypertension in 2007: where are we now? 1799 70

To evaluate the prevalence, etiologic factors and therapy of hypertension in actively followed up transplant population in Saudi Arabia; we retrospectively reviewed the records of the active renal transplant patients at two large transplant centers in Riyadh and Jeddah in Saudi Arabia. These subjects were transplanted between January 1979 and November 1998. The patients were grouped according to the measurement of blood pressure; group 1 (considered normo-tensive): blood pressure below 140/90 mmHg, group2: blood pressure between 140-159/90-99, group 3: blood pressure 160-179/100-109 group 4: equal to or above 180/110. There were 1115 patients' records included in the study. The mean duration of transplantation was 66.9 +/- 50.1 months. According to the level of measured blood pressure, there were 641 (57.5%) patients in the normotensive group (group 1), 404 (36.3%) patients in the mildly hypertensive group (group 2) 64 (5.7%) patients in the moderately severe hypertension group (group 3) and only six (0.5%) patients in the severe hypertension group (group 4). The estimated prevalence of hypertension in this study was almost 85%. We found no significant difference in the prevalence of hypertension in terms of gender, year of transplantation, duration of transplantation, type of donor, number of previous transplants, diagnosis of renal artery stenosis, etiology of kidney disease, diagnosis of diabetes after transplantation, diagnosis of cerebrovascular accidents, or mean dose of prednisolone and cyclosporine. There was a statistically significant association between increased level of blood pressure and old age (above 50 years), original disease associated with hypertension, history of hypertension on dialysis, acute rejection (once or more), presence of protienuria (more than 0.3 mg/day), abnormality of ECG, or serum creatinine above 300 micromol/L. We conclude that hypertension is highly prevalent in the renal transplant population in Saudi Arabia. Risk factors for the development of hypertension or its complication should be more aggressively approached in order to protect the patients and their grafts alike.
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PMID:Hypertension in renal transplantation: saudi arabian experience. 1821 52

Atherosclerotic renal artery disease represents a cause of which little is known but not a cause to be neglected for hypertension and renal insufficiency. Even though its occurrence remains badly defined, atherosclerotic renal artery disease is constantly on the rise due to the aging population, the never prevailing hypertension and diabetes mellitus. This review aims to give a clinical profile of patients presenting with atherosclerotic renal artery disease and to discuss, in the light of study results, which diagnostic evaluation should be used considering the sequence and the benefit and risk of each in order to initiate a personalized treatment. Patients affected by atherosclerotic renal artery disease are likely to have more complications and more extensive target-organ damage than patients without renal artery stenosis. The evolution of the atherosclerotic renal artery disease is in general slow and progressive. Nevertheless, certain clinical cases manifest themselves with the onset of acute renal failure bought upon by the administration of blockers of the rennin-angiotensin-aldosterone system, or by some other causes responsible for a sudden drop in renal plasma flow (e.g., thrombosis of the renal artery). The relationship between atherosclerotic renal artery disease and atherosclerosis is complex, and mediators implicated in the pathophysiology of renovascular disease may also contribute to the progression of cardiovascular damage. An early assumption of the atherosclerotic renal artery stenosis is warranted to determine the adapted treatment (i.e., medical treatment, revascularisation...) just as the assumption and the correction of the more general cardiovascular risk factors.
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PMID:[Atherosclerotic renal artery disease diagnosis update]. 1880 67

Patients with diabetes mellitus are at increased risk for developing peripheral vascular disease and renal artery stenosis (RAS). Furthermore, in diabetic patients the progression of renal atherosclerotic disease toward critical stenosis or occlusion occurs more frequently than in their nondiabetic counterparts. Consequently, clinicians must carry a high level of suspicion for detecting RAS in diabetic patients, particularly those with established coronary and/or peripheral atherosclerotic disease and compromised renal function. In this group of patients early detection of this condition, preferably with a noninvasive diagnostic test, is very important to plan revascularization therapy. In nondiabetic patients, several studies have demonstrated that catheter-based revascularization therapy may arrest or revert renal dysfunction in patients with RAS. Although still the subject of debate, a recent study has shown that in diabetic patients with RAS and impaired renal function, revascularization therapy with endovascular stents has a positive impact in the progression of renal dysfunction.
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PMID:Evaluation and approach to treatment of renal artery stenosis in patients with diabetic nephropathy. 1899 Mar 7

Reno-vascular disease, along with diabetes mellitus, is the leading cause of dialysis in the elderly population, accounting for 50-66% of cases in patients above 65 years of age. Reno-vascular disease is a broad term, which includes renal artery stenosis, ischemic nephropathy, such as atherosclerotic obstruction, thrombo-embolic phenomenon, nephrosclerosis secondary to hypertension and acute occlusion of renal arteries (either bilateral or unilateral in singlekidney patients). Renal artery stenosis, defined as a 50% or greater occlusion of a renal artery (unilateral or bilateral), is an important cause of secondary hypertension. It often presents as drug refractory hypertension or renal insufficiency. Atherosclerotic renal artery stenosis accounts for 90% of such cases, the remaining 10% being caused by fibro-muscular dysplasia. The incidence of atherosclerotic renal artery stenosis is increasing among the aging population, who are at an increased risk due to cardiovascular complications. This is a review of the emerging trends in the diagnosis and management of renal artery stenosis.
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PMID:Renal artery stenosis: an update on diagnosis and management. 1905 47

Renal artery stenosis (RAS) is an important cause of arterial hypertension and chronic kidney disease. The aims of our study were to assess the prevalence of RAS and to examine the frequency of variants of renal vasculature, that is, multiple and/or accessory renal arteries in hypertensive patients referred to renal angiography. We evaluated retrospectively 1554 arteriographies of hypertensive patients. Angiograms were evaluated to find RAS, significant RAS (>60% stenosis of the lumen), radiological signs of atherosclerosis, aneurysms of the renal arteries or aorta and variants of kidney vascularization. The frequency of RAS including occlusions was 15.1% (21.3% of them were significant and suitable for revascularization). Variants of renal arterial vascularization were found in 26.5% of patients (multiple renal arteries-11.2% and accessory renal arteries-15.3%). Significant RAS was found more frequently in patients older than 60 years-OR 4.76 (2.08-10.86). Coronary artery disease, history of myocardial infarction or stroke significantly increased the chance of RAS detection. The frequency of renal accessory arteries was lower in patients older than 60 years and in patients with the radiological signs of atherosclerosis. Results of this study indicate that haemodynamically important RAS is found more frequently in hypertensive patients older than 60 years. Symptomatic atherosclerotic disease found in the peripheral and/or coronary arteries and diabetes mellitus increases the chance of RAS detection. Decreased occurrence of renal accessory arteries was found in hypertensive patients with radiological signs of atherosclerosis.
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PMID:Frequency of renal artery stenosis and variants of renal vascularization in hypertensive patients: analysis of 1550 angiographies in one centre. 1912 56


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