Severe renal failure and thrombotic microangiopathy induced by malignant hypertension successfully treated with spironolactone

Ledesma, Hilda Mercedes Villafuerte; Porta, José María Peña; Gil, Pablo Íñigo; Azara, P; Lalglesia, J.E Ruiz; Latorre, Alejandro Tomas; Burillo, Alba Martinez; Perna, Patricia Vernet; Lipe, Rafael Álvarez

doi:10.1016/j.ancard.2018.04.009

Cited by 7 publications

(4 citation statements)

References 15 publications

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“…Similarly, in patients with resistant hypertension, the BP response to spironolactone is only weakly correlated with the PAC [13], and many patients with low or normal aldosterone still respond to this agent [26]. Furthermore, spironolactone clearly lowered BP in patients with malignant hypertension in whom PRA and the PAC were normal [17]. These ndings suggest that MRA add-on therapy may be effective for lowering BP in patients with malignant hypertension, even though the PAC is normal or low.…”

Section: Discussionmentioning

confidence: 99%

“…Given that hypokalemia and severe hypertension resulting from marked activation of the RAAS are frequently observed during the acute phase in patients with a hypertensive emergency and/or malignant hypertension, it is conceivable that the adverse effects of RAAS combination therapy are bene cial in these patients. However, there is limited research on the effects of DRIs and MRAs in patients with hypertensive emergency and/or malignant hypertension and few relevant case reports [16,17]. Moreover, there are no reports of cases in which combination therapy involving a DRI, MRA, and ACEI or ARB has been used.…”

Section: Introductionmentioning

confidence: 99%

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Successful treatment of severe renal failure caused by malignant hypertension using a combination of renin-angiotensin-aldosterone system inhibitors: a case report

Harada,

Maeoka,

Takahashi

et al. 2024

Preprint

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Background: Marked activation of the renin-angiotensin-aldosterone system (RAAS) plays an important role in hypertensive emergencies, in particular malignant hypertension, by worsening hypertension and renal function. The rates of readmission for severe hypertension and cardiovascular disease in such emergencies are high, suggesting that suppression of the RAAS may be not adequate during the acute phase in some cases. Although treatment with a combination of RAAS inhibitors decreases blood pressure (BP) to a greater extent than monotherapy, its specific impact on malignant hypertension has not been reported. Case presentation: A 41-year-old woman presented with malignant hypertension complicated with renal insufficiency (creatinine 3.93 mg/dL) and massive proteinuria (4.0 g/day). Renal biopsy confirmed malignant nephrosclerosis and thrombotic microangiopathy. Antihypertensive therapy was administered, including an angiotensin receptor blocker (ARB), aliskiren (a direct renin inhibitor), and spironolactone, a nonselective mineralocorticoid receptor antagonist, which preserved renal function effectively and normalized BP. Plasma renin activity was extremely high (131.9 ng/mL/h) on admission but normalized within almost 2 weeks after initiation of antihypertensive treatment. Although aliskiren and spironolactone were discontinued before discharge, BP was well controlled and renal function was further improved (creatinine 1.14 mg/dL) at follow-up 24 months after discharge. Discussion: This case of renal failure induced by malignant hypertension was successfully treated with a combination of RAAS inhibitors (i.e., a direct renin inhibitor, an angiotensin receptor blocker, and a nonselective mineralocorticoid receptor antagonist). The controlled BP and improved renal function during both the short term and long term in this patient suggest that adequate suppression of the RAAS cascade during the acute phase of malignant hypertension is potentially effective in terms of breaking the vicious circle of malignant hypertension and hyperreninemia.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Successful treatment of severe renal failure caused by malignant hypertension using a combination of renin-angiotensin-aldosterone system inhibitors: a case report

Harada,

Maeoka,

Takahashi

et al. 2024

Preprint

View full text Add to dashboard Cite

show abstract

“…[74,75] Several patients have been reported to be in remission with blood pressure control alone without PE. [76–78] In this case, malignant hypertension-induced TMA was considered; however, severe thrombocytopenia was observed and atypical. Several previous reports on COVID-19-related TMA have described patients with a history of hypertension.…”

Section: Discussionmentioning

confidence: 99%

Coronavirus disease 2019-associated thrombotic microangiopathy treated with plasma exchange and antihypertensive therapy in a patient with HIV: A case report with literature review

Masuda,

Fukushima,

Hebisawa

et al. 2023

Medicine

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Rationale: Coronavirus disease 2019 (COVID-19) is an infectious disease that often causes complications in multiple organs and thrombosis due to abnormal blood coagulation. This case report aimed to describe the clinical course of COVID-19-associated thrombotic microangiopathy (TMA) and reviewed the comprehensive information on TMA, thrombotic thrombocytopenic purpura (TTP), and atypical hemolytic uremic syndrome associated with COVID-19 in the past literature. Patient concerns: A 46-year-old Japanese man was diagnosed with human immunodeficiency virus infection 10 years ago and treated with antiretroviral therapy. The patient presented with fever, malaise, hematuria, and bilateral upper abdominal discomfort for the past 4 days. Diagnoses: COVID-19-associated TMA was diagnosed based on a positive polymerase chain reaction for severe acute respiratory syndrome coronavirus 2 and laboratory findings such as thrombocytopenia, acute kidney injury, and hemolytic anemia. Malignant hypertension and human immunodeficiency virus infection were also considered as differential diagnoses of TMA. Interventions: Considering the possibility of TTP, plasma exchange was performed, and glucocorticoids were administered. Hemodialysis was performed for acute kidney injury. Antihypertensive drugs were administered to control the high blood pressure. Outcomes: Platelet count and renal function improved, and hemodialysis was no longer required. The patient was in good general condition and was discharged from the hospital. Lessons: COVID-19-associated TMA should be considered as a differential diagnosis during the COVID-19 epidemic. Excessive inflammation and severe COVID-19 are not essential for TMA development. Early intervention using conventional TMA treatments, such as plasma exchange and corticosteroids, might be important in improving prognosis while differentiating between TTP and atypical hemolytic uremic syndrome. Antihypertensive therapy may be helpful in the treatment of COVID-19-associated TMA.

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“…Malignant hypertension (MH) is characterized by severe hypertension and hypertensive retinopathy that results in bilateral flame-shaped hemorrhages in the retina and papilledema [ 1 , 2 ]. In rare cases, patients with MH exhibit thrombotic microangiopathy (TMA) that develops because of mechanical stress on the red blood cells as they pass through narrowed arteries due to fibrinoid necrosis or edema caused by severe hypertension [ 2 , 3 ].…”

Section: Introductionmentioning

confidence: 99%

Thrombotic Microangiopathy Due to Malignant Hypertension Treated Exclusively With Antihypertensive Therapy

Asano¹,

Mori²

2022

Cureus

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Plasma exchange is the commonly considered therapy for the treatment of thrombotic microangiopathy (TMA); however, it is not always mandatory. We treated a patient who presented with malignant hypertension (MH) complicated by TMA using antihypertensive therapy that was not accompanied by plasma exchange. A 38-year-old woman with photophobia, diarrhea, fever, and severely elevated blood pressure was referred to our hospital. Blood test results revealed thrombocytopenia and hemolytic anemia, and ascites were observed on the computed tomography images. Although TMA was suspected, plasma exchange was not performed because the platelet count was not markedly low. Her blood cell counts improved after antihypertensive treatment, and she was discharged. The patient is currently under therapy and remains stable. Thus, TMA secondary to MH may improve using antihypertensive therapy, without the need for invasive plasma exchange. Considering the platelet count may be helpful in deciding whether plasma exchange is required.

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Severe renal failure and thrombotic microangiopathy induced by malignant hypertension successfully treated with spironolactone

Cited by 7 publications

References 15 publications

Successful treatment of severe renal failure caused by malignant hypertension using a combination of renin-angiotensin-aldosterone system inhibitors: a case report

Successful treatment of severe renal failure caused by malignant hypertension using a combination of renin-angiotensin-aldosterone system inhibitors: a case report

Coronavirus disease 2019-associated thrombotic microangiopathy treated with plasma exchange and antihypertensive therapy in a patient with HIV: A case report with literature review

Thrombotic Microangiopathy Due to Malignant Hypertension Treated Exclusively With Antihypertensive Therapy

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