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Flashcards in L12- Secondary HTN Deck (21)
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Name the 6 causes of secondary HTN that we discuss in this lecture

Chronic Kidney Disease (5%)

Renovascular Disease (4%)

Adrenal Disease (.5%) 

Pheochromocytoma (.2%) 

Genetic causes

Obstructive Sleep Apnea 


Discuss pathology of CKD and HTN

Kidney damage results in fewer functioning nephrons to filter blood (extra sodium and water) so the remaining ones have to work harder -- get intraglomerular HTN and retention so increased CO -- more damage to kidney exacerbating cycle 


Damage leads to inappropriate volume retention and activation of RAS, SNS and NO dysregulation 


What are other problems in CKD treatments that can also contribute to HTN?

Treatment of CKD can lead to secondary Hyperparathyroidism with higher intracellular Ca concentrations leading to stiffer vessels 


Erythropoietin treatment leads to higher Hb and therefore more CO 


What happens in renal artery stenosis?

Reduced flow to those selfish, selfish kidneys causes the Glomerulus to compensate by increasing Renin release to preferentially act on efferent arteriole to constrict it and maintain GFR 

HOWEVER increased AG2 causing increased BP 


When would you suspect Renal Artery stenosis?

start treatment on patient for HTN with Ace-Inhibitor and BP plummets!!! 


So, that's good that you cured the HTN but also discovered the underlying problem is renal artery stenosis. STOP ACE-Inhibitor so you can maintain GFR and prevent kidney damage - dont want to cause CKD! 


What is Captopril?

How can does the Captopril nuclear scan work?

What would be diagnostic results?

Captopril = ACE-Inhibitor 

In scan, inject radio-nucleotide tracer to measure uptake into kidneys and then into bladder/urine over time. Then add Captopril 

DDX = Renal Artery Stenosis if add captopril and see SLOWER renal uptake of drug bc less renal perfusion pressure AND Longer time to get drug to appear in urine 


Serum diagnosis for renovascular disease?

HIGH renin levels in plasma 

Profound drop in BP with ACE-Inhib


Where is Aldosterone released from? What does it do? What can cause Hyper-release?

Aldosterone released from Adrenal Cortex (Glomerulosa) and acts on the Kidney to cause increase Na Retention and K Secretion 


Hyper-Aldosteronism results from Adrenoma, Carcinoma or Hyperplasia of adrenal cortex 


How do you Diagnose Primary HyperAldosteronism?

High Aldosterone

LOW RENIN (suppressed from aldosterone)

LOW SERUM POTASSIUM!!! (high urinary potassium)


What drugs can block Aldosterone's effects on the kidney?

Spironolactone or Eplerenone

aldo antagonists acting at distal tubule 


How does Licorice ingestion (or Kushing's Disease or Obesity or 11-beta-OH deficiency) cause HTN?

Excess Cortisol!!! 

outcompetes Aldosterone at mineralcorticoid receptor and acts similarly 


What are the Monogeneic determinants of HTN?

1) Congenital Adrenal Hyperplasia 

- 21 OH deficiency (90%) = salt wasting

- 11 OH deficiency = HTN, Hypokalemia, elevated 11-deoxycorticosterone

-17 OH deficiency = rae but has sexual problems!!

2) Liddle's Syndrome!! 

(constituitive activation of Amiloride sensitive NA channels and so No ALDOSTERONE at all!)



What is Liddle's syndrome and classica diagnosis for that?

Constant activation of Amiloride sensitive NA channels resulting in HTN and Hypokalemia (reabsorbing too much like excess aldosterone condition) 

DX with High BP, Low K+, and NO ALDOSTERONE! 


What is Glucocorticoid remedial HTN?

Autisomal Dominant form of low renin HTN with hyperaldosteronism bc Aldosterone secretin is controlled by ACTH rather than by AG2

Therefore, complete suppression of Aldosterone by exogenous glucocorticoid use (like dexamethasone)


Treatment - inhibit mineralcorticoid receptor  


What are the possible causes of HTN when you see High Aldosterone and High Renin?

Renovascular (renal artery stenosis)


LV failure 


Renin secreting tumor 


What are the possible causes of HTN when you see High Aldosterone and Low Renin levels?

Adrenal - Adenoma, Hyperplasia, Carcinoma

Familial - GRA (Glucocorticoid remedial)


What are the possible causes of HTN when you see Low Aldosterone and Low Renin?

Apparent mineralcorticoid excess syndrome 

Cushing's Syndrome

Liddle's Syndrome



What are the symptoms of Pheochromocytoma? How does it cause HTN? 

Symptoms - young person with rapid onset of HTN, flushing, tachycardia, sweating, fatigue, palpitations etc 

Dx with Plasma or Urine catecholamine/metanephrine levels

Excess Catecholamines cause sympathetic HTN


How do you treat pheochromocytoma?

Surgical Excision + the ABCs!!!!!

A= Alpha blockers for BP (BEFORE BETA BLOCKERS)

B = Beta blockers for Tachyarrhythmia

C = Catecholamine Synthesis Inhibitors like Methyl-tyrosine 


What is obstructive sleep apnea and how does it cause HTN? Treatment?

When sleeping, neuronal signals to throat are diminished and it collapses (worse in fat people or people on drugs that diminish neural drive) and get intermittent Asphyxia

leads to marked BP elevation


Treatment with Positive Pressure breathing devise