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Letter to the Editor
Resistant hypertension with hyponatraemia
Hipertensión resistente con hiponatremia
María Maldonadoa,
Corresponding author
, Lina Leóna, Cristina Vegaa,b
a Servicio de Nefrología, Hospital Universitario La Paz, Madrid, Spain
b Departamento de Nefrología, Universidad Autónoma de Madrid, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Renovascular hypertension accounts for 1&#8211;2&#37; of the population with hypertension and 5&#46;8&#37; of those with secondary hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Renal artery stenosis with clinical presentation of resistant hypertension with hyponatraemia is rare in adult patients&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In this paper we report a case of hypertensive hypotonic hyponatraemia&#44; review the cases reported in the literature and provide a brief discussion&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 77-year-old woman with a history of hypertension &#40;HTN&#41;&#44; type 2 diabetes mellitus and hypothyroidism&#46; With regard to hypertension&#44; given the difficult control&#44; she required antihypertensive treatment with four drugs&#44; including a diuretic&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">She was admitted in April 2019 for a first episode of congestive heart failure&#46; Complementary tests revealed an atrophic right kidney and a left kidney with a morphological <span class="elsevierStyleItalic">parvus et tardus</span> pattern in the intrarenal arteries&#44; suggestive of stenosis of the left renal artery&#46; She was referred to the nephrology department&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Subsequently&#44; she repeatedly visited the emergency department for HTN&#44; presenting with hyponatraemia&#44; which was initially attributed to the use of thiazides&#46; In addition&#44; there was deterioration of renal function coinciding with the initiation of angiotensin II receptor blockers&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">She was admitted again in May for another episode of congestive heart failure&#44; presenting with impaired renal function&#44; poorly controlled HTN&#44; metabolic alkalosis&#44; hypokalaemia and hyponatraemia&#46; She was assessed by Nephrology who requested a secondary HTN study and showed significant elevation of aldosterone&#44; serum renin and renin activation with a normal aldosterone&#47;renin ratio&#46; A CT scan was performed which revealed a critical segmental stenosis in the left renal artery&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A therapeutic renal angiography with stent placement was performed with improvement of laboratory parameters &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">This case reflects a unilateral renal artery stenosis&#44; a pathology described mainly in the paediatric age group&#44; as described in the study by Ding et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> which reports a total of 15 cases in children &#40;mean age 4 years&#41; with manifestations similar to those of our case&#44; most of which were treated interventionally&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The disease is less common in the adult population&#46; The study by Agarwal et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> which included 32 patients&#44; found it to be more common in older women with heavy smoking&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The renal ischaemia caused by stenosis activates the renin-angiotensin-aldosterone system&#44; which acts on the kidney contralateral to the stenosis&#44; causing an increase in intraglomerular pressure and natriuresis&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> On the other hand&#44; pressure diuresis produces polyuria which increases thirst and leads to volume depletion that stimulates the release of antidiuretic hormone contributing to hyponatremia&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> which can promote the release of aldosterone&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> thus creating a vicious circle&#46; Added to this is the role of angiotensin II in causing thirst and promoting the release of antidiuretic hormone&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Aldosterone and angiotensin II also increase distal tubular potassium loss and hypokalaemia can stimulate renin secretion&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Treatment is based on blood pressure control and the treatment of choice is renal artery revascularisation preferably by percutaneous angioplasty&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> which allows resolution of the impairments&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Unilateral renal artery stenosis is a potentially curable and reversible cause of hypertensive hyponatraemia when diagnosed early and appropriate treatment is implemented&#46; It should be suspected in cases of difficult-to-treat hypertension accompanied by hyponatraemia&#44; hypokalaemia&#44; and metabolic alkalosis&#46;</p></span>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Plasma Osm &#40;mOsm&#47;kg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">276&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">280&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Serum K &#40;mEq&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HCO<span class="elsevierStyleInf">3</span> &#40;mEq&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Serum aldosterone &#40;ng&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Serum renin &#40;mIU&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">289&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Renin activity &#40;ng&#47;mL&#47;h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aldosterone&#47;renin ratio &#40;ng&#47;dL-ng&#47;mL&#47;h&#44; normal value &#60;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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ISSN: 23870206
Original language: English
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