an arterial hypertension: diagnostics and treatment
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K.m.n. E.V.Sorokin of JU.A.carp Institute of cardiology of a name of A.L.Mjasnikova RKNPK MZ the Russian Federation, Moscow Approximately in 3-5 % of cases an arterial hypertension (AG) is secondary under the relation to other diseases. In 70 % of these cases AG the nephritic arterial hypertension” is called by diseases and defeats pochek. the Term switches on enough the big list of diseases which it is possible to divide into 3 basic groups (tab. 1). nesmotrja on a variety of the diseases listed in tab. 1, the pathogenetic mechanism laying â to a basis "nephritic" AG, as a rule, it is uniform - development strengthening in kidneys renina ñ the subsequent activation system renin-angiotensin-aldosteronovoj (RAAS). Besides, the sympathetic nervous system, secretion vazopressina and vazokonstriktornyh prostaglandinov are activated. Parenhimatoznye diseases of kidneys - the most widespread, but, unfortunately, reason quite often hard to cure "nephritic" AG - especially at defeat of both kidneys. gipotenzivnyh means long reception is necessary for the control of arterial pressure (the HELL) as specific, etiotropnaja therapy either is not developed for the majority of these patients, or is ineffective. for elimination AG after kidney transplantation repeated surgical intervention or ballonnaja angioplastika (BAP) nephritic arteries more often is required. Considered further in more details renovaskuljarnuju AG (RVAG) carry most "kurabelnym" to forms "nephritic" AG. It is necessary to remember, that for successful treatment RVAG and preservations of a viable kidney are extremely important timely è the proved diagnosis, and also accurately formulated indications to operative or conservative treatment. RVAG reveal at 1-3 % of all persons suffering AG, in 20 % of all cases resistant AG, in 30 % cases malignant and bystroprogressirujushchej AG. At representatives of black race meets less often, and at Japanese reason RVAG quite often happens chronic nonspecific aortoarteriit (illness Takajasu) to involving of nephritic arteries. Despite the fact that what in 2/3 cases reason RVAG is the atherosclerosis of nephritic arteries, it is necessary to remember, that these terms are not equivalent: Atherosclerotic plaques come to light in nephritic arteries often enough (especially at elderly, at accompanying giperholesterinemii, a diabetes and hypertensive illness), but only then are considered as reason RVAG when call gemodinamicheski a significant stenosis of vessels è an ischemia nephritic parenhimy. To distinctive features RVAG owing to an atherosclerosis carry more frequent occurrence among men is more senior 45-50 years and accompanying atherosclerotic defeat of other vascular pools (an aorta atherosclerosis, coronary and cerebral arteries, vessels of feet). At bilateral defeat of nephritic arteries and an atherosclerosis of an artery of unique kidney RVAG often has a malignant current. Fibromyshechnaja displazija nephritic arteries (FMD) - after an atherosclerosis the reason RVAG second for frequency. At this disease meets displazija a medial layer of nephritic arteries is more often, is more rare - displazija intims and adventitsii. The rule, FMD leads to development AG already in children`s, youthful or middle age, meets at women is more often . At 1/3 patients with FMD AG has a malignant current (usually at bilateral defeat of nephritic arteries). Diagnostics the Clinical signs revealed at inquiry and fizikalnom research, allow only with bolshej or smaller probability to suspect RVAG (tab. 2). to remember low specificity of many anamnesticheskih and fizikalnyh symptoms, for example sistolicheskogo noise in epigastrii which often reveal at intaktnyh nephritic arteries against usual essentsialnoj hypertensions. The standard laboratory researches of blood and urine at RVAG also malospetsifichny - revealed gipokaliemija, high level renina and kreatinina plasmas, proteinurija, sometimes gematurija are quite often found out at essentsialnoj a hypertension and other diseases. In similar cases for specification of diagnostic and medical tactics are necessary additional noninvasive and invazivnye researches (tab. 3). It is necessary to remember, that in view of rather small prevalence RVAG and the limited predictive value of accessible noninvasive methods of diagnostics screening of all patients with stable good-quality AG I-II now is not recommended to degree for revealing of defeat of nephritic arteries. the Purpose of additional methods of research at suspicion on RVAG - to confirm or deny presence gemodinamicheski a significant obstacle to a blood-groove in one or both nephritic arteries, and in case of acknowledgement - to estimate possibility of operative elimination of this obstacle for the purpose of restoration of blood supply of a kidney, and in the long term - decrease the HELL. Intravenous ekskretornaja the urography during present time has practically lost the value at inspection of patients with suspicion on RVAG â communications with small sensitivity and specificity. Besides, it is not necessary to underestimate nefrotoksichnost some rentgenokontrastnyh substances, especially in the conditions of a kidney ischemia . Ultrasonic research of kidneys is the most economic and simple method for screening RVAG. At the heart of a method revealing of asymmetry of kidneys lays. However appreciable changes arise already at far come protsesse. more widely now is used dopplerovskoe blood-groove research â nephritic arteries with which help it is possible to find out blood-groove acceleration â stenosis areas. It is necessary to remember, that value of ultrasonic methods at primary research is limited to the complicated visualisation of nephritic arteries. On various data, nephritic arteries are visualised only at 60-70 % of patients. At research of arteries of the replaced kidney informativnost ultrasonic dopplerografii a little above, as in these cases the nephritic artery is located more superficially. activity Definition renina in peripheral venous blood maloinformativno because of low sensitivity and specificity of results. Value of a method a little above at a blood sampling from the bottom hollow vein in a course invazivnogo researches, however even in this case for definitive verification of the diagnosis are required other methods. From laboratory methods most informatively activity definition renina in the venous blood taken separately from the right and left nephritic veins at their leg of a triangle rizatsii. Signs of an ischemia of one of kidneys is distinction of activity renina in nephritic veins more than in 1,5 times. Attempts to raise diagnostic value of this method by purpose of a saltless diet, nifedipine, gidralazina, captopril are known. From the noninvasive combined laboratory techniques test with captopril is well transferred è easily vypolnima . For 3 sut before test to the patient cancel ingibitory angiotenzinprevrashchajushchego enzyme (APF) and diuretiki. Before a fence of blood of the patient easy sits or lays within 30-60 minutes In the first sample of peripheral venous blood define activity renina plasmas. Through 60 mines after intake 25-50 captopril mg in 10 ml of water again take away blood on activity research renina. consider positive if activity renina after stimulation above 12 ng/ml/ch, the absolute gain of activity exceeds 10 ng/ml/ch, and a relative gain (in comparison with initial level) exceeds 150 % (if initial activity renina below 3 ng/ml/ch - 400 %). radionuklidnaja stsintigrafija kidneys - informative, concerning inexpensive and it is easy vypolnimyj in out-patient and stationary conditions a research method . The method allows to estimate both the general nephritic blood-groove, and speed klubochkovoj filtrations in each kidney. Use the relation of absorption of the indicator each kidney to the general nephritic absorption, time of approach of the maximum absorption and the relation of residual absorption through 20-30 mines to the maximum absorption. Äÿ value radionuklidnoj stsintigrafii essentially raises at its combination to test ñ captopril . In this case inhibition APF blocks konstriktsiju efferentnyh nephritic arteriol, that against lowered perfuzionnogo pressure in the amazed kidney leads to sharp reduction of its function - the absorption size decreases, time of absorption and indicator deducing increases . At intaktnyh and maloizmenennyh arteries kontralateralnoj kidneys its function against reception ingibitorov APF opposite increases also distinction stsintigramm becomes especially evident. Rentgenokompjuternoe and magnitno-resonant (MR) tomograficheskoe research of kidneys allows to specify and compare the sizes of kidneys, and also to exclude sdavlenie nephritic arteries tumours and kistami in area of gate. Mr-angiografija nephritic arteries is a safe and perspective method of noninvasive research, especially at an atherosclerosis of the nephritic arteries, allowing not only to reveal defeat, but and to estimate its localisation and extent, and also to investigate kollateralnuju a network â to the amazed kidney. At diagnostics FMD of nephritic arteries value decreases a little. on diagnostic value at atherosclerosis comes nearer to the gold standard” - rentgenokontrastnoj angiografii. distribution Mr-angiografii while restrains concerning high cost of a technique. Recognizing etalonnost rentgenokontrastnoj angiografii in diagnostics of defeat of nephritic arteries, it is necessary to note, nevertheless, complexity of its carrying out, à also nefrotoksichnost entered in a considerable quantity rentgenokontrastnyh means. the Optimum scheme of diagnostics RVAG is presented on the scheme. It is necessary to underline, that efficiency of laboratory-tool diagnostic search essentially increases at presence at the patient of symptoms RVAG revealed at gathering of the anamnesis è fizikalnom research (tab. 2 see). Treatment Medicamentous treatment at RVAG appoint at impossibility of carrying out revaskuljarizatsii with the help angioplastiki or surgical intervention. At a choice gipotenzivnyh means it is necessary to remember not only decrease the HELL, but also about necessity of improvement of a blood-groove in ishemizirovannoj a kidney, and also possible development of nephritic insufficiency with delay of deducing of medical products. Ingibitory APF at RVAG are rather effective , however it is necessary to remember their ability to worsen function of the amazed kidney at unilateral defeat. Therefore the given class of preparations appoint only at an inefficiency of the others gipotenzivnyh means against a bilateral stenosis of nephritic arteries, and also at artery defeat edinstvenoj a functioning kidney. Thus careful supervision over the patient is necessary. From other means it is necessary to pay attention on antagonists of calcium (nifedipine (Korinfar), etc.) - they do not influence function of the amazed kidney and in some cases are capable to expand nephritic arteries. There are 2 basic of a method of radical correction of defeats of nephritic arteries - ballonnaja angioplastika and surgical revaskuljarizatsija . As the indication to carrying out BAP serves FMD nephritic arteries is more often - at this disease angioplastika usually is a method of a choice and it is less often accompanied by complications . Ïðè an atherosclerosis of nephritic arteries BAP spend less often - basically at local defeats, not mentioning a mouth of a nephritic artery. It is known, that at observance of criteria of selection dilatatsija passes successfully on the average at 50 % of patients with FMD and 50 % of patients with nonspecific aortoarteriitom, but only at 19 % of patients with an atherosclerosis of nephritic arteries. Thus successful dilatatsija the HELL in 60 % of cases is accompanied by decrease. In 5 % of cases after unsuccessful angioplastiki it is necessary emergency surgical intervention , death rate at angioplastike nephritic arteries makes 2 %. Basic complications BAP: rupture è stratification of a nephritic artery, a thrombosis and embolija a nephritic artery with development of a heart attack of a kidney, sharp nephritic insufficiency as a result of introduction of the big doses rentgenokontrastnogo substances. Earlier almost in 30 % of cases within 1 year occurred restenoz a nephritic artery in a place of carrying out BAP. With application stentirovanija this figure has a little decreased, however angioplastika still it is considered choice means at FMD nephritic arteries - restenozy at this disease meet only in 5 % of cases. the Surgical method still remains choice means at treatment of the majority of cases RVAG. Indications to operative vmeshatelstvu: satisfactory total function of kidneys, decrease in function and the sizes of a kidney on the party of a stenosis in the absence of abnormal development or parenhimatoznogo diseases kontralateralnoj kidneys. nefrektomija at defeat of a nephritic artery it is shown at unilateral diseases of nephritic arteries when reconstructive operations are impossible, at a unilateral stenosis of the main nephritic arteries in a combination ñ or parenhimatoznym kidney disease on the party stenoza. Reconstructive operation is shown by abnormal development mainly at unilateral and bilateral limited and aortorenalnom defeats. Contra-indications to surgical treatment vazorenalnoj hypertensions : The expressed infringements of total function of kidneys (uraemia), a sharp brain stroke, a sharp heart attack of a myocardium, symmetry of function and the sizes of kidneys at a unilateral stenosis, abnormal development or parenhimatoznoe disease kontralateralnoj kidneys, or defeat of its arteries, absence of asymmetry of a nephritic blood-groove and asymmetry of secretion renina (at unilateral defeat). the Haemodynamic efficiency angioplastiki and reconstructive surgical interventions estimate with the help radionuklidnoj stsintigrafii, Mr-angiografii, rentgenokontrastnoj angiografii and activity definitions renina at separate kateterizatsii nephritic veins. it is necessary to remember, that normalisation the HELL after successful operative intervention or selection of adequate medicamentous therapy does not prevent the further development of the basic pathological process (an atherosclerosis or aortoarteriit) and along with gipotenzivnoj therapy further it is necessary for patient to spend regular treatment of the basic disease. the Literature 1. Braunwald E., Editor. Heart Disease. Textbook of Cardiovascular Medicune 5th edition. W.B. Saunders Company, 1998. 2. Caplan N. M. Clinical Hypertension 5th Edition, Williams and Wilkins, 1990. 3. Eardley K.S., Lipkin G.W. Atherosclerotic renal artery stenosis: is it worth diagnosing? J. Hum Hypertens 1999 Apr; 13 (4: 217-20). 4. Hertz S.M., Holland G.A., Baum R.A., Haskal Z.J., Carpenter J.P. Evaluation of renal artery stenosis by magnetic resonance angiography Am J. Surg 1994 Aug; 168 (2):140-3. 5. Sobel B.J., Bakris G.L. Hypertension: A clinician’s guide to diagnosis and treatment. Hanley and Belfus/Mosby, 1995. 6. Stimpel M. Arterial Hypertension” Walter de Gruyter, 1996. 7. Arabidze G. G Symptomatic arterial hypertensions” in kn.: Heart and vessels ”under the editorship of akad. E.I.Chazova. M: Medicine, 1992; 3: 196-225. 8. Arabidze G. G, Belousov J.B., JU.A.arterial`s Carps a hypertension. a management on diagnostics and treatment. M: Remedium, 1999. 9. 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