Elevated Plasma Renin Activity Caused by Accelerated-malignant Hypertension in a Patient with Aldosterone-producing Adenoma Complicated with Renal Insufficiency

Maruhashi, Tatsuya; Amioka, Michitaka; Kishimoto, Seiji; Ikenaga, Hiroki; Oki, Kenji; Ishida, Mari; Kihara, Yasuki; Higashi, Yukihito

doi:10.2169/internalmedicine.2327-18

Cited by 5 publications

(7 citation statements)

References 21 publications

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“…PRA was extremely high in our patient in comparison with previous reports on malignant hypertension [7,[19][20][21][22] (Fig. 3).…”

Section: Discussionsupporting

confidence: 59%

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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“…PRA was extremely high in our patient in comparison with previous reports on malignant hypertension [7,[19][20][21][22] (Fig. 3).…”

Section: Discussionsupporting

confidence: 59%

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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“…In the beginning, the lesion was interpreted as an incidentaloma, as the values of aldosterone and urinary catecholamines were normal. However, to confirm this hypothesis and exclude rare forms of hyperaldosteronism with increased renin levels in the malignant phase as previously described by other authors, 4,5 were repeated the hormonal dosages in the following months. Repeated laboratory tests at intervals of 4 months showed a significant increase in DRC dissociated from plasma aldosterone values (Table 2) and pressure values (Figure 1).…”

Section: Discussionmentioning

confidence: 56%

“…Alternatively, the adrenal adenoma could be related to a rare form of primary hyperaldosteronism in which the plasma renin activity is initially elevated and subsequently suppressed. 4,5 On the other hand, an extrarenal renin-producing tumor is extremely rare. 6 During hospitalization, progressive reduction in blood pressure values was obtained up to normal level.…”

Section: N O N -C O M M E R C I a L U S E O N L Ymentioning

confidence: 99%

Malignant hypertension and hyperreninemia: primary or secondary hypertension? A case report

et al. 2021

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Malignant hypertension is a rare condition characterized by severe hypertension and multi-organ ischemic damage. Marked activation of renin-angiotensin system is observed in many patients, but its persistence over time is not known. We report a case of 42-year-old woman presented with severe hypertension and multi-organ damage. Initial evaluation showed elevated value of direct renin concentration with normal plasma aldosterone concentration, and a nodular lesion in the left adrenal gland. The differential diagnosis between primary and secondary form of hypertension had to be questioned. Consequently the patient was followed up for 20 months. Repeated checks showed a significant increase in renin levels with a normal aldosterone concentration and regression of organ damage. After 20 months renin values returned within normal limits. Hyperreninemia persisting over a long period of time has not been fully explained. Long term follow-up allowed us to attribute malignant hypertension to de novo essential hypertension.

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“…[4] Common factors causing negative ARR include potassium status, sodium loading, pregnancy, antihypertensive drugs, some complicating diseases such as OSA and renal insufficiency and some undiscovered causes. [3,[5][6][7][8][9][10][11][12] These negative ARRs may have different causes, but they all generally occur in the context of normal or normal-high renin. As the ARR is strongly influenced by the PRC as the denominator of the ratio such that minor changes in renin may lead to considerable changes in the ARR.…”

Section: Discussionmentioning

confidence: 99%

Case series: Primary aldosteronism diagnosed despite normal screening investigations: A report of three cases

Jia

Lin

et al. 2023

Medicine

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Rationale: Since the introduction of the aldosterone-to-renin ratio (ARR) as a screening tool for primary aldosteronism (PA), there has been a marked increase in the reported prevalence of this condition among hypertensive, even normotensive, subjects.Patient concerns: But ARR as a spot blood draw for estimating a patient's aldosterone secretory status is influenced by many factors.Diagnoses: Here, we describe a series of patients with biochemically confirmed PA, whose diagnosis was delayed by the initial ARR assessment with non-suppressed renin.Interventions: Patient 1 had a history of resistant hypertension for many years and had a negative initial screening for secondary hypertension (including ARR). At the reevaluation, ARR was close to cutoff still with normal renin after strict and extended drug washout, and the further workup for PA demonstrated a unilateral aldosterone producing adenoma that was surgically removed, with subsequent complete biochemical remission and partial clinical success. Patient 2 was diagnosed with idiopathic hyperaldosteronism combined with obstructive sleep apnea syndrome, which could increase renin resulting in a negative ARR, and finally got a better treatment effect with PA-specific spironolactone, as well as continuous positive airway pressure. Patient 3 with hypokalemia as the main presentation was finally diagnosed with PA after excluding other diseases, and proceeded to laparoscopic adrenalectomy and histologically confirmed an aldosterone producing adenoma. Postoperatively, patient 3 achieved complete biochemical success without any medicine.Outcomes: The clinical status of all three patients was effectively managed, resulting in either complete resolution or notable improvement of their respective conditions.Lessons: After rigorous standardized diagnostic evaluation, there are still many reasons for ARR negative in PA, but they all basically occur in the background of normal or normal-high renin without suppression. A negative screening test result should be repeated and analyzed carefully if this is not consistent with the clinical picture. If, despite a repeatedly negative ARR, clinical suspicion remains high, we recommend consideration of further evaluation, including confirmatory tests and adrenal venous blood sampling (AVS) or even 68Ga-pentixafor PET/CT to better confirm the diagnosis and improve patient outcomes.Abbreviations: APA = aldosterone-producing adenoma, ARR = aldosterone-to-renin ratio, AVS = adrenal venous blood sampling, BMI = body mass index, CKD = chronic kidney disease, CPAP = continuous positive airway pressure, CT = computed tomography, OSA = obstructive sleep apnea syndrome, PA = primary aldosteronism, PAC = plasma aldosterone concentration, PRC = plasma renin concentration, RAAS = renin-angiotensin-aldosterone system.

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Elevated Plasma Renin Activity Caused by Accelerated-malignant Hypertension in a Patient with Aldosterone-producing Adenoma Complicated with Renal Insufficiency

Cited by 5 publications

References 21 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

Malignant hypertension and hyperreninemia: primary or secondary hypertension? A case report

Case series: Primary aldosteronism diagnosed despite normal screening investigations: A report of three cases

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