Long-term renal outcome in patients with malignant hypertension: a retrospective cohort study

Abstract

BackgroundMalignant hypertension is frequently complicated by renal insufficiency. Although the survival of this hypertensive emergency has improved, recent data on renal outcome and its predictors are lacking. We assessed renal outcome and its predictors in patients with malignant hypertension.MethodsRetrospective analysis of patients admitted with malignant hypertension in Amsterdam, the Netherlands between August 1992–January 2010. Follow-up data on vital status, renal function and blood pressure (BP) were obtained from the outpatient department and from general practitioners. The primary composite endpoint was end-stage renal disease (ESRD) defined as the start of kidney replacement therapy (KRT) or ≥ 50% decline of estimated glomerular filtration rate (eGFR). The secondary endpoint was all cause mortality.ResultsA total of 120 patients admitted with malignant hypertension were included. After a median follow-up period of 67 months (IQR 28 to 108 months) the primary endpoint was reached by 37 (31%) patients, whereas 18 patients (15%) reached the secondary endpoint. Twenty-nine (24%) patients started KRT and 8 patients (7%) had an eGFR decline ≥ 50%. After the acute phase (> 3 months after admission), initial serum creatinine and follow-up BP were the main predictors of future ESRD with hazard ratios of 6.1 (95% CI, 2.2–17) for patients with initial serum creatinine ≥ 175 μmol /L and 4.3 (95% CI, 1.4–14) for patients with uncontrolled hypertension.ConclusionsProgressive renal function decline leading to ESRD remains a major threat to patients with malignant hypertension. BP control during follow-up was an important modifiable predictor of renal outcome.

Mortality and Cardiovascular Risk in Patients With a History of Malignant Hypertension: A Case‐Control Study

“…Patients with MHT had a favorable cardiovascular risk profile compared with HT controls but had severe renal dysfunction. Since uncontrolled hypertension is the only modifiable predictor of long-term renal outcome and mortality in patients with MHT, 4 tight BP control should be the primary goal in the management of patients with history of MHT.…”

“…To overcome this, we performed a sensitivity analysis showing that no patients with a history of MHT who visited the emergency department between 1992 and 2008 were missed. 4 Secondly, the age range of SUNSET participants was limited to 35 to 60 years, whereas the patients with a history of MHT were aged 19 to 79 years. Nonetheless, most patients with a history of MHT who fell outside this age range were younger than 35, implying a lower mortality risk, and the mean age of deceased patients was similar among all groups.…”

“…[1][2][3] With the availability of antihypertensive drugs and improved patient care, mortality has been markedly reduced to approximately 10% after 5 years. 2,4 This is still considerable, however, given the relatively young study populations, with an average age varying between 40 and 50 years at presentation. 2,5 Previous cohort studies, including our own, have shown that renal dysfunction is an important predictor of mortality in patients with MHT, 2,4 while other studies suggest a role of traditional cardiovascular risk factors such as excess smoking, decreased levels of highdensity lipoprotein (HDL), and poor blood pressure (BP) control.…”

“…2,4 This is still considerable, however, given the relatively young study populations, with an average age varying between 40 and 50 years at presentation. 2,5 Previous cohort studies, including our own, have shown that renal dysfunction is an important predictor of mortality in patients with MHT, 2,4 while other studies suggest a role of traditional cardiovascular risk factors such as excess smoking, decreased levels of highdensity lipoprotein (HDL), and poor blood pressure (BP) control. [6][7][8][9] However, most of these studies lack a control population thereby limiting the internal validity.…”

“…The selection of patients with a history of MHT has been previously described. 4 Briefly, we searched the database of a large teaching hospital in Amsterdam, The Netherlands. The diagnosis at discharge is recorded in this database according to the International Classification of Diseases (ICD) codes.…”