The Vascular-Renal Connection in Patients Hospitalized With Hypertensive Crisis: A Population-Based Study

A Triple Mystery of Insidious Organ Failure: Are the Lung, Kidney and Brain All Damaged by the Ageing Pulse?

This review explores the hypothesis that dementia in several forms, chronic kidney disease and idiopathic pulmonary fibrosis have a common cause in pulse-induced capillary haemorrhage. All three conditions are age-related and characterised by insidious onset, uncertainty about their cause, exacerbation by hypertension, resistance to treatment and the relentlessness of their progression. We argue that the three conditions are the clinical outcomes of damage caused by pulse-induced haemorrhage from capillaries. The damage, first detectable in mid-life, creates first mild and then severe symptoms of cognitive, renal and pulmonary dysfunction. We also review evidence that in all three organs there has developed, by young adulthood, a reserve of tissue that enables them to function well, despite the 'heartbeat by heartbeat' damage that accumulates from early mid-life; and that it is when that reserve is exhausted, typically in late age, that symptoms of organ failure emerge and progress. If this common cause can be established, a step will have been taken towards the understanding, treatment and delay of three conditions that have their beginnings in every individual and that, in those who survive other causes of death, become lethal in late age.

Inflammatory cytokines are associated to lower glomerular filtration rate in patients with hypertensive crisis

Introduction

Hypertension and kidney function are closely related. However, there are few studies on renal function during acute elevation of blood pressure (BP), denominated hypertensive crisis (HC).

Objectives

To evaluate the relationship between renal function and inflammatory cytokines in HC, subdivided into hypertensive urgency (HUrg) and emergency (HEmerg).

Materials and methods

This cross-sectional study was carried out in 74 normotensive (NT) and 74 controlled hypertensive individuals (ContrHT) followed up in outpatient care. Additionally, 78 subjects with hypertensive emergency (HEmerg) and 50 in hypertensive urgency (HUrg), attended in emergency room, were also evaluated. Hypertensive crisis was classified into HEmerg, defined by systolic blood pressure (BP) ≥ 180 mmHg and/or diastolic BP ≥ 120 mmHg in presence of target-organ damage (TOD), and HypUrg, clinical situation with BP elevation without TOD. The glomerular filtration rate (eGFR) was estimated, and cytokine levels were measured. Statistical analysis was performed using the Kruskal-Wallis or Mann-Whitney test and Spearman’s correlation, with significant differences p-value < 0.05.

Results

The median age was 53.5 years in the NT group (52 female), 61 years in the ContrHT group (52 female), and 62.5 years in the HC group (63 female) (p-value < 0.0001). The median BP was 118.5/75 mmHg for NT, 113.5/71 for ContrHT, and 198.5/120 mmHg for HC, respectively (p-value < 0.0001 among groups). BP and heart rate levels were significantly higher in the HC group compared to the NT and ContrHT groups (P < 0.001 for all). The eGFR was significantly lower in HC group compared to the NT and ContrHT groups. The cytokine levels were higher in the HEmerg and HUrg groups compared to ContrHT group (P < 0.0001, except for IL-1β in HUrg vs. ContrHT), without difference between the acute elevation of BP groups. Thus, all cytokines were significantly elevated in patients with HC compared to the control groups (NT and ContrHT). There was a negative correlation between eGFR and the cytokines (IL-1β, IL-6, IL-8, IL-10, and TNF-α) in the HC group.

Conclusion

Elevated inflammatory cytokines are associated with reduced eGFR in individuals with HC compared to control groups, suggesting that the inflammatory process participates in the pathogenesis of acute elevations of BP.

Current U.S. Guideline-Based Management Strategies for Special Clinical Situations Involving Hypertensive Crises: A Narrative Review of the Literature

Hypertensive crises, although somewhat rare in hypertensive patients, might become an increasingly relevant issue in the future as the number of adults living with hypertension in the United States increases. Many of the current U.S. clinical guidelines for the treatment and management of a variety of medical conditions do not factor hypertensive crises into their recommendations or only consider them in a limited fashion in the context of other medical conditions. This review article summarizes the definitions of hypertensive crises/urgent hypertension/emergent hypertension, the epidemiological profile and outcomes of patients, current U.S. clinical guidelines' recommendations for the general treatment of hypertensive crises, and current U.S. clinical guidelines' recommendations for the treatment of acute kidney injuries, acute ischemic stroke, aortic dissection, and acute heart failure in relation to hypertensive crises. All physicians who manage hypertensive patients, but particularly physicians who work in intensive care units, emergency departments and in U.S. hospitals, should review hypertensive crises guidelines and relevant treatments, and understand current recommendations.

Hypertensive Emergencies: A Review of Common Presentations and Treatment Options

Approximately 33% of adults in the United States have high blood pressure; approximately 1% will present with a hypertensive emergency. Hypertension emergency is typically defined as a blood pressure great than 180/120 mmHg leading to end organ damage. However, it is important to note that an acute rise in blood pressure may also lead to end organ damage before achieving the blood pressure threshold. Therapeutic intervention should be a short-acting, easily titratable, intravenous antihypertensive medication based on the type of end-organ damage, pharmacokinetics, and comorbidities. This review focuses on presentations and treatment of hypertensive emergency.