以肾脏受累为主要表现的恶性高血压临床病理分析

Malignant hypertension presenting with renal damage: a clinical and pathological analyses

目的 了解以肾脏受累为主要表现的恶性高血压 (MHPT)患者的临床与肾脏病理特征。方法 回顾性分析我院肾内科 11年来收治的 2 7例 (男 2 1例 ,女 6例 ,年龄 19～ 5 1岁 )MHPT患者的血压、眼底、尿和肾功能变化 ,对比分析原发性和肾实质性MHPT的临床与肾脏病理改变。结果 2 7例MHPT患者中原发性、肾实质性和肾血管性分别为 10例 (37 0 % )、10例 (37 0 % )和 1例 (3.7% ) ,病因不明 6例 (2 2 .3% )。急进性肾炎综合征和进行性肾功能损害是肾脏受累的主要表现。与肾实质性MHPT相比 ,原发性的MHPT尿蛋白量较少 (P =0 .0 0 1) ,多数病人有高血压家族史 (7/10 )。 13例MHPT肾脏病理 :原发性MHPT肾小动脉纤维素样坏死、内膜重度增生 ,呈现典型的洋葱皮样改变 ,肾小球为缺血性改变 ;肾实质性肾小动脉壁厚 ,细动脉玻璃样变 ,肾小球呈严重炎症病变。部分原发性MHPT经长期治疗肾功能可明显改善。结论 以肾脏受累为主要表现的MHPT不少见 ,临床易误、漏诊 ;原发性与肾实质性MHPT的临床。

Objective To evaluate the clinical features and pathological characteristics of malignant hypertension (MHPT) with renal damage. Methods The blood pressure, eye ground, urinalysis, renal function and extrarenal presentations of malignant hypertension patients, who had been hospitalized in recent eleven years, were analyzed retrospectively. There were 27 patients, 21 males and 6 females, aged from 19 to 51 years. At the same time, the clinical and pathological features of primary MHPT were compared with those of renal parenchymal MHPT. Results Among these patients, primary hypertension was diagnosed in 10 cases (37%), glomerulonephritis in 10 cases (37%), renovascular hypertension in 1 case (3.7%), and undetermined etiology in 6 cases (22.3%). The common renal presentations were those of rapidly progressive glomerulonephritis (RPGN) and progressive renal failure. Compared with those who were diagnosed as renal parenchymal MHPT, primary MHPT patients had lower urinary protein excretion ( P =0.001) and most of them had family history of hypertension. Renal biopsy was done in 13 cases, revealing primary MHPT in 4 cases and glomerulonephritis in 9. Typical pathological findings for primary MHPT were fibroid necrosis, marked intimal hyperplasia (“onion skin” like change) and ischemic changes of glomeruli. Severe glomerulonephritis, hyalinosis and thickening of renal arterioles were the main changes in MHPT with renal parenchymal diseases. After intensive therapy, the renal functions of some primary MHPT patients improved markedly. Conclusion Malignant hypertension presenting with renal damage was not very rare. It was usually misdiagnosed. The clinical presentations, pathological findings and prognosis of primary MHPT were different from those of renal parenchymal MHPT.