A 29-year-old male patient with a history of neurofibromatosis type II and bilateral vestibular schwannomas was referred for evaluation of new-onset proteinuria. The patient's schwannomas were inoperable, and he was treated with bevacizumab 10 mg/kg intravenously every 3 weeks. After 18 months of therapy, serial imaging showed stabilization of the schwannoma size and sequential monitoring of urine analyses showed newonset proteinuria without changes in kidney function. Bevacizumab was discontinued and he was referred for nephrology evaluation. His physical examination was notable for elevated blood pressure (153/93 mm Hg) but was otherwise unremarkable. Laboratory evaluation included complement concentrations; serum-free light chain levels; serum and urine protein electrophoresis; and antinuclear antibody, antineutrophil cytoplasmic antibody, hepatitis B virus, hepatitis C virus, HIV, and anti-M-type phospholipase A 2 receptor serologies; all were noncontributory. Urine dipstick gave negative results for blood and urine microscopy examination was unremarkable. The patient was treated conservatively with an angiotensin receptor blocker. Six months later, there was no improvement in his proteinuria and a kidney biopsy was performed (Fig 1).
Purpose of review
This review will focus on hypertension due to underlying adrenal disorders in chronic kidney disease (CKD). Diagnosis of adrenal hypertension and particularly primary aldosteronism (PA) in CKD is frequently not pursued. We outline limitations that advanced kidney disease poses on the diagnostic work up of these disorders and provide a framework for approaching CKD patients suspected of having an adrenal disorder. Recognition of these disorders is important as they are often underdiagnosed which leads to poorer outcomes.
Recent findings
Adrenal disease associated with hypertension in CKD is most commonly due to PA whereas pheochromocytoma and Cushing's disease are important but less common. Diagnosis of these diseases is important as their identification leads to better blood pressure control and can possibly mitigate the risk of progression of CKD. Work up and treatment of PA has been shown to be safe and is associated with less antihypertensive medication requirement for the associated hypertension and slower progression of CKD.
Summary
This chapter summarizes the importance of recognizing adrenal hypertension in CKD and reinforces the need for physicians to pursue these diagnoses in CKD patients as this is safe and improves both BP control and delays progression of CKD.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.