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Dietary salt intake and renal damage in patients with primary aldosteronism before and after treatment
Journal of the American Society of Hypertension 9(4S) (2015) e119–e120
SECONDARY HYPERTENSION P-213 Dietary salt intake and renal damage in patients with primary aldosteronism before and after treatment Cristiana Catena, Gianluca Colussi, Francesca Nait, Francesca Pezzutto, Flavia Martinis, Gabriele Brosolo, Leonardo A. Sechi. Internal Medicine, University Of Udine, Italy, Udine, Italy Primary aldosteronism is associated with renal changes that include glomerular hyperfiltration and increased urinary protein excretion that recede after treatment. Although animal studies indicate that dietary salt content is critical for occurrence of aldosterone-related renal damage, there is no evidence of this interaction in patients with primary aldosteronism. The aim of this study was to examine the relevance of dietary salt intake, as assessed by measurement of 24-hour urinary sodium excretion (UNaE), and renal damage in primary aldosteronism before and 1 year after surgical or medical treatment. In 46 patients with primary aldosteronism (age 5312 yr.; 32 males) we measured glomerular filtration rate (GFR) by 24-hour creatinine clearance, and 24-hour urinary sodium (UNaE) and albumin excretion (UAE). Diagnosis of primary aldosteronism was established after screening with the aldosterone-to-renin ratio and subsequent confirmation by a saline load test. Twenty-two patients had bilateral adrenal hyperplasia and 24 adrenal adenoma and were treated with mineralocorticoid receptor antagonists or unilateral adrenalectomy, respectively. Measurements were repeated in all patients one year after treatment. Before treatment, UAE was significantly related with UNaE (r¼0.388; P<0.01) both in patients with unilateral and bilateral disease. However, when GFR was included in a multivariate regression analysis the relationship between UAE and UNaE was lost. At follow-up and as expected, GFR and UAE declined significantly both in patients treated with mineralocorticoid receptor antagonists and adrenalectomy, whereas UNaE did differ significantly from baseline. Univariate analysis of correlation did not show any relationship of UNaE with UAE in patients treated medically or surgically. In conclusion, dietary salt intake is associated with the extent of subclinical renal damage in primary aldosteronism, but this association is explained by glomerular hyperfiltration and therefore could be attributed to the functional changes occurring in the kidney of these patients. Keywords: Primary aldosteronism; salt intake; renal damage P-214 Secondary hypertension due to juxtaglomerular cell tumour (reninoma) Igor Nunes, Tiago Santos, Sara Croca, Alberto Figueira, Jo~ao Coutinho, Leonor Carvalho, Jose Braz Nogueira. Centro Hospitalar Lisboa Norte Hospital Santa Maria, Lisbon, Portugal Hypertension (HT) is an ubiquitous condition with an estimated global prevalence of 30%. Essential HT accounts for the majority of cases but a secondary cause can be identified in 5-20% of patients. The ethiology of secondary HT is diverse and includes rare conditions such as juxtaglomerular tumours (JGT). JGT are exceedingly rare: to date there are only 100 cases described worldwide. Most frequently, women between 20 and 30 years of age are affected and the final diagnosis which is based on pathology findings requires a high clinical awareness. We describe the case of a 22 year old Caucasian woman, referred to a Hypertension Outpatient clinic at a tertiary reference centre with the provisional diagnosis of secondary HT. When first assessed, she was being treated with
a calcium channel blocker, direct renin inhibitor and diuretic (spironolactone) with inadequate blood pressure (BP) control. Target organ damage at presentation included concentric left ventricular hyperthrofy and proteinuria. Further investigation revealed normal catecholamine levels, hypokalaemia and slightly elevated renin levels (234 pg/mL) which were attributed to treatment with a renin antagonist. A renal angio-computed tomography (CT) showed normal renal arteries and a small nodule on the right kidney but was otherwise unremarkable. Despite escalation of treatment with full dose quadruple regimen, BP remained persistently high. Renine levels were repeated and found to be exceedingly raised (3400 pg/mL). Angio-CT was also repeated showing the same nodule previously described which remained unchanged. The hypothesis of JGT was considered and the patient underwent successful laparoscopic tumorectomy with apparently free surgical margins. Anatomopathological examination confirmed the diagnosis. During the post-operative period, a rapid decline in BP was observed. At 4-month follow-up, renin levels have steadily declined (40pg/mL) and the patient remains normotensive without any treatment. Keyword: Reninoma
P-215 Arousals and nocturnal hypertesion Ivan Porter, William Haley, Nabeel Aslam, Bhupendra Rawal, Paul Fredrickson. Mayo Clinic Florida, Jacksonville, FL, United States Background: Studies have demonstrated the association between obstructive sleep apnea and nocturnal hypertension (NH) where activation of the sympathetic nervous system in a repetitive sequence contributes to increased cardiovascular risk. Ambulatory blood pressure monitoring (ABPM) can detect the presence of NH, missed on office visit blood pressure monitoring. NH and a non-dipping pattern (<10%) increases the risk of adverse renal and cardiovascular outcomes. A growing body of evidence suggests that periodic limb movements of sleep (PLMS) influence vascular morbidity. The present study investigates the relationship between PLMS and NH. Methods: A retrospective review from January 1, 2010 to December 31, 2012 of subjects at our institution with both ABPM and polysomnography performed within a six month timeframe was performed. This criterion was met by 190 individuals: 56% male and 91% white. Charts were reviewed for demographic data, results of 24 hour ABPM and polysomnography, concurrent medication use by class, comorbid conditions and serum/urine lab data. 8 patients were excluded due to incomplete measurements on ABPM. Results: Patients with NH were more likely to be diabetic, have worse sleep efficiency and, as expected, have an elevated apnea-hypopnea index (AHI, number of events per hour of sleep). There was not an association of NH with limb movement index (LMI) (OR¼1, p-value¼0.88) though there was a trend with the total number of arousals per hour of sleep (p-value¼0.06). Controlling for age, the LMI was associated with all type arousals (OR¼1.07, p¼0.019). Patients with a LMI>25 were, however, more likely to be older, have a fib and DM. Analysis of this data suggests a possible correlation between NH and all type arousals. Conclusion: Elevated arousal indices were more prevalent in those with NH. Interestingly, the data does point toward a conclusion that cortical arousals of all types may predict a non-dipping pattern and risk for NH; however, this relationship approached, but did not reach, statistical significance. This analysis does not confirm an association between NH and PLMS however; further investigation is warranted in light of evidence suggesting a relationship with vascular morbidity.
1933-1711/$ - see front matter Ó 2015 American Society of Hypertension. All rights reserved.
SECONDARY HYPERTENSION P-213 Dietary salt intake and renal damage in patients with primary aldosteronism before and after treatment Cristiana Catena, Gianluca Colussi, Francesca Nait, Francesca Pezzutto, Flavia Martinis, Gabriele Brosolo, Leonardo A. Sechi. Internal Medicine, University Of Udine, Italy, Udine, Italy Primary aldosteronism is associated with renal changes that include glomerular hyperfiltration and increased urinary protein excretion that recede after treatment. Although animal studies indicate that dietary salt content is critical for occurrence of aldosterone-related renal damage, there is no evidence of this interaction in patients with primary aldosteronism. The aim of this study was to examine the relevance of dietary salt intake, as assessed by measurement of 24-hour urinary sodium excretion (UNaE), and renal damage in primary aldosteronism before and 1 year after surgical or medical treatment. In 46 patients with primary aldosteronism (age 5312 yr.; 32 males) we measured glomerular filtration rate (GFR) by 24-hour creatinine clearance, and 24-hour urinary sodium (UNaE) and albumin excretion (UAE). Diagnosis of primary aldosteronism was established after screening with the aldosterone-to-renin ratio and subsequent confirmation by a saline load test. Twenty-two patients had bilateral adrenal hyperplasia and 24 adrenal adenoma and were treated with mineralocorticoid receptor antagonists or unilateral adrenalectomy, respectively. Measurements were repeated in all patients one year after treatment. Before treatment, UAE was significantly related with UNaE (r¼0.388; P<0.01) both in patients with unilateral and bilateral disease. However, when GFR was included in a multivariate regression analysis the relationship between UAE and UNaE was lost. At follow-up and as expected, GFR and UAE declined significantly both in patients treated with mineralocorticoid receptor antagonists and adrenalectomy, whereas UNaE did differ significantly from baseline. Univariate analysis of correlation did not show any relationship of UNaE with UAE in patients treated medically or surgically. In conclusion, dietary salt intake is associated with the extent of subclinical renal damage in primary aldosteronism, but this association is explained by glomerular hyperfiltration and therefore could be attributed to the functional changes occurring in the kidney of these patients. Keywords: Primary aldosteronism; salt intake; renal damage P-214 Secondary hypertension due to juxtaglomerular cell tumour (reninoma) Igor Nunes, Tiago Santos, Sara Croca, Alberto Figueira, Jo~ao Coutinho, Leonor Carvalho, Jose Braz Nogueira. Centro Hospitalar Lisboa Norte Hospital Santa Maria, Lisbon, Portugal Hypertension (HT) is an ubiquitous condition with an estimated global prevalence of 30%. Essential HT accounts for the majority of cases but a secondary cause can be identified in 5-20% of patients. The ethiology of secondary HT is diverse and includes rare conditions such as juxtaglomerular tumours (JGT). JGT are exceedingly rare: to date there are only 100 cases described worldwide. Most frequently, women between 20 and 30 years of age are affected and the final diagnosis which is based on pathology findings requires a high clinical awareness. We describe the case of a 22 year old Caucasian woman, referred to a Hypertension Outpatient clinic at a tertiary reference centre with the provisional diagnosis of secondary HT. When first assessed, she was being treated with
a calcium channel blocker, direct renin inhibitor and diuretic (spironolactone) with inadequate blood pressure (BP) control. Target organ damage at presentation included concentric left ventricular hyperthrofy and proteinuria. Further investigation revealed normal catecholamine levels, hypokalaemia and slightly elevated renin levels (234 pg/mL) which were attributed to treatment with a renin antagonist. A renal angio-computed tomography (CT) showed normal renal arteries and a small nodule on the right kidney but was otherwise unremarkable. Despite escalation of treatment with full dose quadruple regimen, BP remained persistently high. Renine levels were repeated and found to be exceedingly raised (3400 pg/mL). Angio-CT was also repeated showing the same nodule previously described which remained unchanged. The hypothesis of JGT was considered and the patient underwent successful laparoscopic tumorectomy with apparently free surgical margins. Anatomopathological examination confirmed the diagnosis. During the post-operative period, a rapid decline in BP was observed. At 4-month follow-up, renin levels have steadily declined (40pg/mL) and the patient remains normotensive without any treatment. Keyword: Reninoma
P-215 Arousals and nocturnal hypertesion Ivan Porter, William Haley, Nabeel Aslam, Bhupendra Rawal, Paul Fredrickson. Mayo Clinic Florida, Jacksonville, FL, United States Background: Studies have demonstrated the association between obstructive sleep apnea and nocturnal hypertension (NH) where activation of the sympathetic nervous system in a repetitive sequence contributes to increased cardiovascular risk. Ambulatory blood pressure monitoring (ABPM) can detect the presence of NH, missed on office visit blood pressure monitoring. NH and a non-dipping pattern (<10%) increases the risk of adverse renal and cardiovascular outcomes. A growing body of evidence suggests that periodic limb movements of sleep (PLMS) influence vascular morbidity. The present study investigates the relationship between PLMS and NH. Methods: A retrospective review from January 1, 2010 to December 31, 2012 of subjects at our institution with both ABPM and polysomnography performed within a six month timeframe was performed. This criterion was met by 190 individuals: 56% male and 91% white. Charts were reviewed for demographic data, results of 24 hour ABPM and polysomnography, concurrent medication use by class, comorbid conditions and serum/urine lab data. 8 patients were excluded due to incomplete measurements on ABPM. Results: Patients with NH were more likely to be diabetic, have worse sleep efficiency and, as expected, have an elevated apnea-hypopnea index (AHI, number of events per hour of sleep). There was not an association of NH with limb movement index (LMI) (OR¼1, p-value¼0.88) though there was a trend with the total number of arousals per hour of sleep (p-value¼0.06). Controlling for age, the LMI was associated with all type arousals (OR¼1.07, p¼0.019). Patients with a LMI>25 were, however, more likely to be older, have a fib and DM. Analysis of this data suggests a possible correlation between NH and all type arousals. Conclusion: Elevated arousal indices were more prevalent in those with NH. Interestingly, the data does point toward a conclusion that cortical arousals of all types may predict a non-dipping pattern and risk for NH; however, this relationship approached, but did not reach, statistical significance. This analysis does not confirm an association between NH and PLMS however; further investigation is warranted in light of evidence suggesting a relationship with vascular morbidity.
1933-1711/$ - see front matter Ó 2015 American Society of Hypertension. All rights reserved.