Nephrosclerosis - arteriolar

Alternative names
Accelerated hypertension; Arteriolar nephrosclerosis; Malignant hypertension; Hypertension - malignant

Definition
Malignant hypertension is usually defined as very high blood pressure with swelling of the optic nerve behind the eye, called papilledema (grade IV Keith-Wagner hypertensive retinopathy). Malignant hypertension is usually accompanied by other organ damage like heart failure, kidney failure, and hypertensive encephalopathy.

Causes, incidence, and risk factors

The disorder affects about 1% of people with high blood pressure, including both children and adults. It is more common in younger adults, especially African American men. It also occurs in women with toxemia of pregnancy, and people with kidney disorders or collagen vascular disorders. You are at high risk for malignant hypertension if you have had kidney (renal) failure or Renal hypertension caused by renal artery stenosis.

Malignant hypertension is a medical emergency. Many body systems are in serious risk due to the extreme elevation of blood pressure. Multiple organs of the body, including the brain, eyes, blood vessels, heart, and kidneys may sustain damage. The blood vessels of the kidney are highly susceptible to damage caused by pressure, and kidney failure may develop, which may be permanent.

Symptoms

     
  • blurred vision  
  • headache  
  • change in mental status       o restlessness       o anxiety       o decreased alertness, decreased ability to concentrate       o fatigue       o sleepy, stuporous, lethargic       o confused, delirious  
  • chest pain       o mid chest location most common       o crushing or pressure sensation  
  • shortness of breath  
  • cough  
  • decreased urinary output  
  • nausea or vomiting  
  • seizure  
  • weakness of the arms, legs, face, or other areas  
  • abnormal sensation (numbness) of the arms, legs, face, or other areas

Signs and tests
Your blood pressure may be extremely high. An eye examination will reveal changes that indicate high blood pressure, including papilledema (swelling of the optic nerve), retinal bleeding, or infarction (cotton wool spots or soft exudate - fluid with cellular debris) in the retina. If not already present, kidney failure may develop as a complication of malignant hypertension. Other complications may also develop.

Damage to the kidneys may be demonstrated by:

     
  • BUN increase  
  • Creatinine increase  
  • Arterial blood gas analysis showing metabolic acidosis  
  • Urinalysis showing high proteinlevels (especially with kidney impairment) or microscopic blood in the urine)

A chest x-ray may indicate pulmonary (lung) congestion from fluid forced into the lungs by heart failure as a consequence of the high blood pressure.

This disease may also alter the results of the following tests:

     
  • Urinary casts  
  • Renin  
  • Aldosterone

Treatment
Hospitalization is essential until the severe high blood pressure is under control. Medications delivered through an IV line, such as nitroprusside, nitroglycerin, or others, may reduce your blood pressure.

After the severe high blood pressure is brought under control, anti-hypertensive medications taken by mouth can control your blood pressure. The medication may need to be adjusted occasionally. Hypertension can be difficult to control.

Expectations (prognosis)
If treated promptly, malignant hypertension is often controlled without permanent complications. If it is not treated promptly, complications may be severe and life-threatening.

Complications

     
  • recurrence of malignant hypertension episodes  
  • damage to the brain from:       o hypertensive encephalopathy       o spasm or constriction of the arteries of the brain       o swelling       o stroke       o seizures       o intracerebral hemorrhage       o coma  
  • pressure damage to the eyes, permanent blindness  
  • pressure damage to the heart       o decreased cardiac output       o Heart attack       o angina  
  • pulmonary edema  
  • kidney failure

Calling your health care provider

Go to the emergency room or call your local emergency number (such as 911) if symptoms of malignant hypertension develop. This is an emergency condition!

Call your health care provider if you know you have poorly controlled high blood pressure.

Prevention
If you have high blood pressure, carefully monitoring your blood pressure and taking your medicines properly help to reduce the risk.

Johns Hopkins patient information

Last revised: December 7, 2012
by Mamikon Bozoyan, M.D.

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