肾动脉狭窄合并恶性高血压的临床特点

Clinical characteristics of renal artery stenosis complicated with malignant hypertension

目的了解肾动脉狭窄(RAS)所致恶性高血压(MHT)的发病情况、临床特点和预后。方法回顾性分析北京大学第一医院23年间所有经肾动脉造影证实为RAS的病例,将其中合并MHT的23例列为研究对象,收集其临床及实验室资料,并与同时期收治的46例肾实质性MHT以及23例原发性MHT患者进行比较。结果23例RAS合并MHT患者占同期MHT患者的25.8%、RAS患者的19.5%,其中动脉粥样硬化性肾动脉狭窄(ARAS)在1990年前仅占20.0%,而1990年后已成为首位病因。RAS合并MHT组有别于其他两组的特点包括双侧肾脏大小不一致(52.2%)、血管杂音(17.4%)以及应用血管紧张素转换酶抑制剂(ACEI)后Scr升高超过30%(8.7%)。此外RAS合并MHT组较肾实质性MHT者尿蛋白量低犤(1.6±1.5)g/d比(4.0±3.1)g/d犦,血尿也少见。血压控制满意后RAS合并MHT组尿蛋白转为阴性或降至1.0g/d以下,而肾实质性MHT组尿蛋白无显著下降。RAS合并MHT组行血管重建治疗的11例患者中6例高血压得到完全控制(54.5%)。在3～12个月的随访中RAS合并MHT组中有2例进入维持性透析治疗(均为入院时即存在肾功能不全的患者),少于其他原因引起的MHT患者。结论RAS是继发性MHT常见的病因。对于尿液中有形成分不多、蛋白尿定量<3.5g/d的MHT患者应积极进行RAS的相关筛检。在不同病因导致的MHT中。

Objective To investigate the incidence, clinical characteristics and prognosis of malignant hypertension (MHT) resulted from renal artery stenosis (RAS).Methods Among those diagnosed as RAS by arteriography over a 23 year period (From January 1980 to April 2003), 23 patients complicated with malignant hypertension(MHT) were included. Their etiology, clinical characteristics,treatment and prognosis were analyzed, and compared with those of 46 renal parenchymal MHT and 23 primary MHT cases during in the same period.Results Twenty three patients accounted for 25 8%of MHT cases and 19 5%of RAS cases during the same period.Among 23 patients, atherosclerotic renal artery stenosis (ARAS) and Takayasu arteritis were most commonly seen, and ARAS became the leading cause after 1990.The distinct characteristics of RAS included unilateral small kidney(52 2%), abdominal or flank bruit(17 4%)and azotemia induced by treatment with angiotensin converting enzyme inhibitor(8.7%).Besides, compared with renal parenchymal MHT group, the level of urine protein in RAS with MHT group was less and all decreased to less than 1 g/d after blood pressure was controlled.Furthermore, hematuria was seldom in RAS with MHT group. As for basal renal function, serum creatinine level in the majority in RAS with MHT group was normal, while most patients of the other two groups had elevated or remarkably elevated serum creatinine level.Hypertension was cured in 54 5%of those receiving interventional therapy in RAS with MHT group. During the follow up 3～12 months, only 2 cases in RAS with MHT group were dialysis dependent, who were less than those in other groups.Conclusions RAS is a common cause of secondary MHT, and the percentage of ARAS is increasing. For MHT patients without hematuria and massive proteinuria, screening for renal artery stenosis is strongly recommended. Although prognosis of RAS is comparatively good, early diagnosis and treatment are crucial.