Abstract
Purpose
In patients with resistant hypertension and large blood pressure fluctuations, the role of orthostatic hypertension, associated with position-dependent renal perfusion disturbances, has not been investigated in detail yet.
Methods
In this regard, four patients from our outpatient clinic were investigated by the use of 24-h ambulatory blood pressure monitoring (ABPM), active standing test, renal duplex sonography and Tc99m-mercaptoacetyltriglycine [MAG3] renal scintigraphy in supine and upright position.
Results
Four patients (three males and one female; 51–79 years) with a mean of 4.25 antihypertensive drugs including a diuretic were evaluated. The recorded blood pressure fluctuations were up to 89/58–198/121 mmHg. Three patients exhibited an extreme and one a normal dipping pattern in the 24-h ABPM. Three patients demonstrated a hypertensive orthostatic reaction in the active standing test. By duplex sonography, a bilateral decrease in the overall intrarenal resistive indices was shown in two patients, a unilateral overall decrease in one patient and a localized decrease in the last patient. From a morphological standpoint of view, all patients had a normal anatomical position and a physiologic descent of both kidneys. But the normalized tubular extraction rate was pathologic in all patients in the upright body position and normalized when lying down in three patients.
Conclusions
Position-dependent renal perfusion should be considered in patients with large blood pressure fluctuations and extreme dipping. If morphological imaging shows no abnormalities, functional imaging provides additional information. Further investigation is needed, foremost if nephropexy could improve blood pressure control in some of these patients.
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References
Calhoun DA, Jones D, Textor S, Goff DC, Murphy TP, Toto RD, White A, Cushman WC, White W, Sica D, Ferdinand K, Giles TD, Falkner B, Carey RM (2008) Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Circulation 117(25):e510–e526. doi:10.1161/CIRCULATIONAHA.108.189141
Brown MA, Buddle ML, Martin A (2001) Is resistant hypertension really resistant? Am J Hypertens 14(12):1263–1269. doi:10.1016/s0895-7061(01)02193-8
Caro JJ, Speckman JL, Salas M, Raggio G, Jackson JD (1999) Effect of initial drug choice on persistence with antihypertensive therapy: the importance of actual practice data. Can Med Assoc J 160(1):41–46
Bhatt H, Siddiqui M, Judd E, Oparil S, Calhoun D (2016) Prevalence of pseudoresistant hypertension due to inaccurate blood pressure measurement. J Am Soc Hypertens 10(6):493–499. doi:10.1016/j.jash.2016.03.186
Roger VL, Go AS, Lloyd-Jones DM, Adams RJ, Berry JD, Brown TM, Carnethon MR, Dai S, de Simone G, Ford ES, Fox CS, Fullerton HJ, Gillespie C, Greenlund KJ, Hailpern SM, Heit JA, Ho PM, Howard VJ, Kissela BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Makuc DM, Marcus GM, Marelli A, Matchar DB, McDermott MM, Meigs JB, Moy CS, Mozaffarian D, Mussolino ME, Nichol G, Paynter NP, Rosamond WD, Sorlie PD, Stafford RS, Turan TN, Turner MB, Wong ND, Wylie-Rosett J, on behalf of the American Heart Association Statistics C, Stroke Statistics S (2011) Heart disease and stroke statistics—2011 update: a report from the American Heart Association. Circulation 123(4):e18–e209. doi:10.1161/CIR.0b013e3182009701
Ram CV, Engelman K (1979) Pheochromocytoma—recognition and management. Curr Probl Cardiol 4(1):1–37
Shibao C, Arzubiaga C, Roberts LJ, Raj S, Black B, Harris P, Biaggioni I (2005) Hyperadrenergic postural tachycardia syndrome in mast cell activation disorders. Hypertension 45(3):385–390. doi:10.1161/01.hyp.0000158259.68614.40
Streeten DH, Auchincloss JH Jr, Anderson GH Jr, Richardson RL, Thomas FD, Miller JW (1985) Orthostatic hypertension. Pathogenetic studies. Hypertension 7(2):196–203
Streeten DH, Anderson GH Jr, Richardson R, Thomas FD (1988) Abnormal orthostatic changes in blood pressure and heart rate in subjects with intact sympathetic nervous function: evidence for excessive venous pooling. J Lab Clin Med 111(3):326–335
Kario K, Eguchi K, Nakagawa Y, Motai K, Shimada K (1998) Relationship between extreme dippers and orthostatic hypertension in elderly hypertensive patients. Hypertension 31(1):77–82
Fornara P, Doehn C, Jocham D (1997) Laparoscopic nephropexy: 3-year experience. J Urol 158(5):1679–1683
Narath PA (1961) Nephroptosis. Urol Int 12(4–5):164–190
Plas E, Daha K, Riedl CR, Hubner WA, Pfluger H (2001) Long-term followup after laparoscopic nephropexy for symptomatic nephroptosis. J Urol 166(2):449–452. doi:10.1016/S0022-5347(05)65961-7
Prandota J, Ostrowska-Skora J (1984) Normal limits for renal mobility in children. Int J Pediatr Nephrol 5(3):171–174
Barber NJ, Thompson PM (2004) Nephroptosis and nephropexy—hung up on the past? Eur Urol 46(4):428–433. doi:10.1016/j.eururo.2004.03.023
De Zeeuw D, Burema J, Donker AJM, Van Der Hem GK, Mandema E (1977) Nephroptosis and hypertension. The Lancet 309(8005):213–215. doi:10.1016/S0140-6736(77)91013-3
Leisner B, Büll U, Rohloff R, Hast B, Heinze HG (1975) Bilateral determination of 131-I-hippuran clearance in nephroptoses within the scope of sequential camera scintigraphy. Nuklearmedizin Archiv 14(2):125–132
Andriole VT, Bonadio M, Bianchi C (1974) The influence of postural changes on the glomerular filtration rate in nephroptosis. Yale J Biol Med 47(4):268–276
Fritzberg AR, Kasina S, Eshima D, Johnson DL (1986) Synthesis and biological evaluation of technetium-99m MAG3 as a hippuran replacement. J Nucl Med 27(1):111–116
Taylor A Jr, Eshima D, Alazraki N (1987) 99mTc-MAG3, a new renal imaging agent: preliminary results in patients. Eur J Nucl Med 12(10):510–514
Al-Nahhas AA, Jafri RA, Britton KE, Solanki K, Bomanji J, Mather S, Carroll MA, Al-Janabi M, Frusciante V, Ajdinowic B et al (1988) Clinical experience with 99mTc-MAG3, mercaptoacetyltriglycine, and a comparison with 99mTc-DTPA. Eur J Nucl Med 14(9–10):453–462
Taylor AT Jr, Fletcher JW, Nally JV Jr, Blaufox MD, Dubovsky EV, Fine EJ, Kahn D, Morton KA, Russell CD, Sfakianakis GN, Aurell M, Dondi M, Fommei E, Geyskes G, Granerus G, Oei HY (1998) Procedure guideline for diagnosis of renovascular hypertension. Society of Nuclear Medicine. J Nucl Med 39(7):1297–1302
Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M, Dahm JB, Deharo JC, Gajek J, Gjesdal K, Krahn A, Massin M, Pepi M, Pezawas T, Ruiz Granell R, Sarasin F, Ungar A, van Dijk JG, Walma EP, Wieling W (2009) Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 30(21):2631–2671. doi:10.1093/eurheartj/ehp298
Kario K, Eguchi K, Hoshide S, Hoshide Y, Umeda Y, Mitsuhashi T, Shimada K (2002) U-curve relationship between orthostatic blood pressure change and silent cerebrovascular disease in elderly hypertensives: orthostatic hypertension as a new cardiovascular risk factor. J Am Coll Cardiol 40(1):133–141. doi:10.1016/S0735-1097(02)01923-X
Eguchi K, Kario K, Hoshide S, Hoshide Y, Ishikawa J, Morinari M, Hashimoto T, Shimada K (2004) Greater change of orthostatic blood pressure is related to silent cerebral infarct and cardiac overload in hypertensive subjects. Hypertens Res 27(4):235–241
Clorius JH, Kjelle-Schweigler M, Ostertag H, Möhring K (1978) [131I] Hippuran renography in the detection of orthostatic hypertension. J Nucl Med 19(4):343–347
Strohmeyer DM, Peschel R, Effert P, Borchert O, Janetschek G, Bartsch G, Frauscher F (2004) Changes of renal blood flow in nephroptosis: assessment by color doppler imaging, isotope renography and correlation with clinical outcome after laparoscopic nephropexy. Eur Urol 45(6):790–793. doi:10.1016/j.eururo.2003.12.011
Cristol L, Walker B, Henrich WL (1996) Distal vessel atherosclerosis as a cause for false-positive renal scintigraphy. Ren Fail 18(6):923–930
Taylor AT (2014) Radionuclides in nephrourology, part 2: pitfalls and diagnostic applications. J Nucl Med 55(5):786–798. doi:10.2967/jnumed.113.133454
Takahara N, Saga T, Inubushi M, Kusuhara H, Seki C, Ito S, Oyama N, Yokoyama O, Sugiyama Y, Fujibayashi Y (2013) Drugs interacting with organic anion transporter-1 affect uptake of Tc-99m-mercaptoacetyl-triglycine (MAG3) in the human kidney: therapeutic drug interaction in Tc-99m-MAG3 diagnosis of renal function and possible application of Tc-99m-MAG3 for drug development. Nucl Med Biol 40(5):643–650. doi:10.1016/j.nucmedbio.2013.03.006
Rizwan AN, Burckhardt G (2007) Organic anion transporters of the SLC22 family: biopharmaceutical, physiological, and pathological roles. Pharm Res 24(3):450–470. doi:10.1007/s11095-006-9181-4
Duan P, Li S, Ai N, Hu L, Welsh WJ, You G (2012) Potent inhibitors of human organic anion transporters 1 and 3 from clinical drug libraries: discovery and molecular characterization. Mol Pharm 9(11):3340–3346. doi:10.1021/mp300365t
Shikano N, Kanai Y, Kawai K, Ishikawa N, Endou H (2004) Transport of 99mTc-MAG3 via rat renal organic anion transporter 1. J Nucl Med 45(1):80–85
Vormfelde SV, Schirmer M, Hagos Y, Toliat MR, Engelhardt S, Meineke I, Burckhardt G, Nurnberg P, Brockmoller J (2006) Torsemide renal clearance and genetic variation in luminal and basolateral organic anion transporters. Br J Clin Pharmacol 62(3):323–335. doi:10.1111/j.1365-2125.2006.02655.x
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Schiefer, J., Amthauer, H., Genseke, P. et al. Position-related renal perfusion disturbances as a possible underestimated mechanism in patients with resistant hypertension: a case vignette. Int Urol Nephrol 49, 1823–1833 (2017). https://doi.org/10.1007/s11255-017-1656-1
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DOI: https://doi.org/10.1007/s11255-017-1656-1