What is renal damage in malignant hypertension?

  1. Summary of medical history Male, 51 years old. He was admitted to the hospital on October 11, 2003, mainly because of “dizziness, lumbar acidity and weakness for 3 months”. The patient was admitted to a local hospital 10 days ago with no apparent cause of dizziness, lumbar acidity and fatigue, accompanied by increased nocturnal urination. Blood pressure was 230/130 mmHg. Urine protein ++++, red blood cells 10-12/high magnification, white blood cells 0-1/high magnification. 24-hour urine protein quantification 9.1 g. Serum total protein 47 g/L, albumin 25 g/L, blood creatinine The diagnosis was “chronic glomerulonephritis (nephrotic syndrome)? Chronic renal insufficiency failure stage, renal hypertension”. After treatment with antihypertensive therapy, the symptoms were relieved. In order to clarify the diagnosis and further treatment, he was referred to our hospital. At the time of admission, the symptoms were: dizziness, lumbago, weakness, emaciation, slight nausea, bitterness in the mouth, poor appetite, frequent nocturnal urination (3~4 times per night), normal bowel movements.  Physical examination: T36.8℃, BP160/95mmHg. The tongue is light and dark, with a slightly yellowish coating, and the pulse is sunken and slippery.  Laboratory examination: blood RBC 2.93×1012/L, WBC 5.3×109, HGB 85g/L, N0.67, L 0.26. urine protein ++, erythrocytes 5~7/high magnification field, urine bitemporal microscopy: 85% of heterogeneous erythrocytes, 24-hour urine protein quantification 1.22g. blood creatinine 264µmmol/L, creatinine Clearance 29.3ml/min, urea nitrogen 12.5mmol/L. Serum total protein 49g/L, albumin 29g/L, total cholesterol 4.0mmol/L, triglyceride 1.55mmol/L, calcium 2.0mmol/L, phosphorus 1.47mmol/L, bicarbonate 29mmol/L. HBsAg(-), glutamate transaminase 13U /ANA (-), anti-dsDNA (-), anti-ENA (-), anti-Sm antibody (-), anti-RNP antibody (-), anti-GBM antibody (-), P-ANCA (-), C-ANCA (-). Ultrasound of both kidneys: right kidney 9.1×4.0×3.9 cm, cortical thickness 1.1 cm, left kidney 9.8×4.5×4.3 cm, cortical thickness 1.2 cm; color multispectral ultrasound of both renal arteries showed no abnormality. Electrocardiogram showed: left ventricular hypertension, ST-T wave changes. Fundus examination: arteriosclerotic fundus grade III.  Admission diagnosis: chronic glomerulonephritis? Chronic renal insufficiency in decompensated stage, renal anemia, renal hypertension.  Treatment: (1) Chinese medicine for strengthening the spleen and kidney, tonifying Qi and blood 1 dose daily (prescription: Radix Astragali 15g, Radix Angelicae Sinensis 12g, Radix Codonopsis Pilosulae 12g, Rhizoma Chuanxiong 12g, Rhizoma Atractylodes Macrocephalae 12g, Poria 12g, Semen 9g, Asparagus 12g, Licorice 3g). (2) Blood pressure control: nifedipine extended-release tablets 20mg twice daily, metoprolol tartrate 12.5mg twice daily. (3) Symptomatic treatment: Calcium Jianbei 0.75, 3 times daily; Sulforaphane 0.1, 3 times daily; Ning Hongxin 4000 units, subcutaneous injection, 2 times a week; baking soda 1.5, 3 times daily. (4) After 2 weeks of the above treatment, the blood pressure was stabilized at 140~145/90~95 mmHg, and a renal biopsy was performed under ultrasound guidance on October 28, 2003. Light microscopy: renal puncture tissue showed 9 glomeruli, fibrous necrosis of glomerular capillaries, ischemic vesicles of GBM, focal atrophy of renal tubules, granular and vacuolar degeneration of epithelial cells, focal lymphoid and mononuclear cell infiltration and fibrosis of renal interstitium, fibrous thickening of small arterial walls, and glassy changes in the walls of some small arteries entering the bulb. Immunofluorescence and electron microscopy: no specific manifestations. It is consistent with renal arteriosclerotic kidney damage. Combining the clinical and pathological findings, a case discussion was held on November 4, 2003 to clarify the diagnosis and decide the next treatment plan.     2. Medical record discussion Resident Dr. Zhao Yu: According to the diagnostic criteria of malignant hypertension: (1) blood pressure was sharply elevated with diastolic blood pressure ≥ 130 mmHg; (2) fundus lesions showed hemorrhage and exudation (fundus grade III lesions) and/or optic papillary edema (fundus grade IV lesions). Combined with this patient’s blood pressure and fundus findings, malignant hypertension could be diagnosed. There are two major categories of malignant hypertension, primary and secondary. This patient belongs to primary malignant hypertension secondary to renal damage or primary glomerular disease based on secondary malignant hypertension please superior analysis. The patient has been complaining of dizziness, lumbago, and weakness for 3 months, so she was diagnosed with “vertigo” in Chinese medicine. The etiology and pathogenesis of vertigo have been discussed by many physicians over the ages, such as Suwen. For example, in Su Wen… (The Great Treatise on the Supreme Spirit), it is said that “all winds and dizziness belong to the liver”, indicating that dizziness is closely related to the liver. Ling Shu. In “Wei Qi” (Wei Qi), it is said that “upper deficiency leads to dizziness”, and in “Ling Shu. The “deficiency of upper qi” in the “Kouwen” and the “marrow sea” in the “Lingshu. The “deficiency of the marrow and sea” in the “Hai Lun” and the “deficiency of the marrow and sea” in the “Ling Shu. Zhang Zhongjing of the Han Dynasty considered phlegm as one of the causes of vertigo and suggested that “no phlegm makes vertigo”. “The patient is suffering from kidney qi deficiency and the bladder has no power to gasify, so he has frequent nocturnal urination; kidney qi deficiency makes the blood vessels weak, so the tongue is pale and dark; kidney qi deficiency makes the water metabolism abnormal at night, so water-dampness stops inside, and water-dampness stagnates for a long time and causes heat, so the tongue is yellowish and greasy. The tongue coating is yellowish and the pulse is thin and slippery. In view of the patient’s evidence and tongue and pulse, the TCM diagnosis is: deficiency of kidney qi, stasis of blood blocking the ligaments, and phlegm blocking the ligaments. Chinese medicine treatment: benefiting Qi and invigorating Blood, drying dampness and resolving phlegm. Traditional Chinese medicine prescription: Tonic Yang Returning Five Soup combined with Han Xia Bai Zhu Tian Ma Tang plus reduction (15 grams of raw Astragalus, 12 grams of Angelica, 15 grams of Dilong, 12 grams of Red and White Peony each, 12 grams of Chuanxiong, 15 grams of Fu Ling, 15 grams of Ze Di, 9 grams of Qing Han Xia, 12 grams of Bai Zhu, 12 grams of Tian Ma). The above analysis is correct or not, please correct the superior physician.  Attending physician Wang Li: The diagnostic ideas of malignant hypertension include the following facets: (1) whether it is malignant hypertension. We agree with Dr. Zhao Yu’s diagnostic analysis of malignant hypertension. (2) Establish whether it is primary or secondary malignant hypertension. The main aspects of differentiation were age of onset, family history of hypertension, 24-hour urine protein quantification, damage to other target organs such as the heart and cerebrovascular, and renal pathology. The patient was over 50 years old, had a family history of hypertension, 24-hour urine protein quantification was greater than 3.5 grams, but decreased significantly after blood pressure control, no acute cerebrovascular accident and acute left heart failure and other complications, especially renal pathology biopsy showed no obvious glomerular lesions, but mainly glomerular capillary lesions, so the test was false primary hypertension secondary to renal damage. (3) Renal function judgment. The main judgment of its renal function damage is acute renal failure or chronic renal insufficiency. Although the patient’s medical history was only 3 months, he had anemia, hypocalcemia and hypophosphatemia and bilateral renal atrophy, so his renal impairment should be considered as chronic renal insufficiency. (4) The presence of cardiovascular and cerebrovascular comorbidities. From the analysis of clinical symptoms and physical and chemical examination results, the damage to other important target organs such as heart and brain due to malignant hypertension was not obvious. In conclusion, the patient could be diagnosed with primary malignant hypertension secondary to renal damage, chronic renal insufficiency, and renal anemia. Treatment. (1) After the previous treatment, the current blood pressure was maintained at 140~145/90~95 mmHg, which was not at the ideal level, and it was recommended to change nifedipine extended-release tablets to 20 mg 3 times daily. (2) TCM diagnosis and treatment analysis. Although the patient had vertigo symptoms, the most prominent and basic manifestation was not vertigo, and her back pain and weakness were more obvious. The term “deficiency labor” is a general term for a variety of chronic weakness diseases in which the main pathogenesis is the decline of the function of the internal organs and the deficiency of qi, blood, yin and yang. There are various causes of “deficiency labor”. There are six causes of deficiency disease”, “there are congenital causes, acquired causes, external causes, situational causes, and medical causes”, from the medical history, this patient is mainly related to congenital deficiency of endowment and acquired overwork. Chinese medicine pays attention to two points: First, to identify the deficiency of qi, blood, yin and yang of the five organs. Although there are many symptoms of deficiency labor, they are not different from the five organs, and the identification of the five organs is not different from qi, blood, yin and yang. Therefore, the identification of deficiency labor should be based on qi, blood, yin and yang as the outline, and the deficiency of the five organs as the goal. As in “The Source of Miscellaneous Diseases. Although the five organs are divided, all the five organs are hiding essence, so there are four losses, namely qi deficiency, blood deficiency, yang deficiency and yin deficiency. The sufferer now feels sore, weak, dizzy, poor, nausea, frequent night urination, so the deficiency is mainly manifested as spleen and kidney deficiency. The second is to identify the presence or absence of concurrent evidence, paying special attention to the presence or absence of manifestations of deficiency leading to reality. The patient’s tongue is pale and dark, which is due to Qi deficiency and weak blood flow, forming stasis of blood. Therefore, Chinese medicine identifies the deficiency of Qi in the spleen and kidney, with damp-heat and blood stasis. The treatment is to benefit Qi and invigorate Blood, clear heat and dampness. As the damp-heat is more in the middle and lower jiao, can we use Tonic Yang Returning Five Soup combined with Wenzhi Tang plus or minus.  Attending physician Li Shen: The diagnosis of renal disease should generally include four aspects: (1) clinical diagnosis. The patient had back pain, weakness, dizziness, decreased serum albumin, massive proteinuria, microscopic hematuria (and glomerulogenic hematuria), elevated blood creatinine, and hypertension, so the diagnosis of chronic glomerulonephritis was first considered clinically. (2) Pathological diagnosis: The patient’s renal pathology was diagnosed as renal arteriosclerotic renal damage, and the glomeruli were basically normal. The patient’s 24-hour urine protein quantification had reached 9.1 grams, mainly due to increased glomerular capillary permeability during malignant blood pressure, resulting in a large amount of proteinuria and red blood cells. After strict control of blood pressure, the 24-hour urine protein quantification had significantly decreased, thus also indicating that his urine protein was closely related to malignant hypertension. Without renal pathological examination, it is difficult to distinguish clinically whether it is primary malignant hypertension secondary to renal damage or primary glomerular disease secondary to malignant hypertension, while through renal pathological examination, it can be clearly diagnosed as primary malignant hypertension secondary to renal damage. (3) The renal function judgment agreed with the analysis of Dr. Wang Li, and chronic renal insufficiency was considered. (4) Diagnosis of comorbidities. The current patient was mainly combined with renal anemia. For the treatment of malignant hypertension, the following two issues should be noted: First, once malignant hypertension occurs, high priority should be given to actively lowering blood pressure. With the lowering of blood pressure small vessel damage may improve, renal pathological changes may be partially reversed, and fibrinoid necrosis of small renal arteries may be absorbed. Renal function impairment may be terminated or improved. Inadequate perfusion of vital organs caused by too rapid a lowering of blood pressure should be avoided during treatment. The initial goal of blood pressure lowering: for malignant hypertensive patients without heart, brain, kidney and other important organ comorbidities can be more stable in 24~48 hours to slowly lower the blood pressure to 160~170/100~105mmHg. end goal: after the blood pressure is stabilized, gradually add oral antihypertensive drugs to make the blood pressure reach below 140/85~95mmHg. second, the antihypertensive drugs are mainly calcium ion antagonists, β-blockers, etc. Angiotensin-converting enzyme inhibitors (ACEI) or angiotensin-converting enzyme receptor antagonists (ARB) should not be used because the renal puncture results of this patient suggested that his glomerular capillaries were ischemically altered, and ACEI or ARB could aggravate the ischemic renal injury. The specific medication agreed with Dr. Wang Li’s opinion. Three additional comments on the diagnosis, identification and treatment of TCM: (1) Pay attention to the differentiation between deficiency labor and vertigo with qi and blood deficiency. The various symptoms of deficiency labor are mainly a series of symptoms of deficiency of essence and qi, while the vertigo with deficiency of qi and blood also has symptoms of deficiency of qi and blood, but vertigo is the most prominent and basic manifestation. The patient’s dizziness is accompanied by symptoms such as lumbago, weakness and frequent nocturia, so the diagnosis of deficiency labor is more appropriate. (2) Pay attention to the combination of identification of symptoms and disease when prescribing medicine. The patient has chronic renal insufficiency, although her stool is normal once a day, in order to promote the excretion of toxins in chronic renal insufficiency, it is recommended to add 9g of Jiao Da Huang to the formula, which can not only detoxify the internal organs, but also activate blood circulation and remove blood stasis. (3) Combination of oral Chinese medicine and Chinese medicine enema. According to his renal function, it is recommended to take one Chinese medicine enema every night, prescription of Chinese medicine enema: 30g of raw rhubarb, 15g of gong ying, 30g of calcined keel, 30g of calcined oyster. Deputy Chief Physician Zhanyong Li: The patient’s renal impairment should belong to Rapidly Progressive Renal Failure (RPRF). RPRF is a common clinical syndrome. RPRF syndrome is a rapidly progressive deterioration of renal function that occurs over a period of weeks to months due to a variety of causes, and is characterized by a progressive increase in blood creatinine levels, imbalance in water, electrolyte and acid-base balance, and uremic symptoms. RPRF is different from both acute renal failure (ARF) and chronic renal failure (CRF), in that ARF is a sudden deterioration of renal function that occurs within a few days. CRF is a slow onset deterioration of renal function over a year. The main causes of RPRF include acute glomerulonephritis (mainly crescentic nephritis), other etiologies include partial malignant hypertension, systemic vasculitis, thrombotic microangiopathy, bilateral renal artery stenosis, drug-related nephropathy, rapidly progressive interstitial fibrosis, obstructive nephropathy, tumor-associated nephropathy, etc. RPRF often turns into CRF if not managed promptly. The patient’s clinical diagnosis was malignant hypertension, renal pathology biopsy mainly showed glomerular capillary fibrous necrosis, GBM ischemic zouaves (his serum anti-neutrophil cytoplasmic antibody was negative, which could exclude systemic vasculitis renal damage), and renal function progressed rapidly within 3 months. Combined with the above analysis, his exact diagnosis should be: primary malignant hypertensive renal damage with rapidly progressive renal failure. The key to Western medicine treatment is to control hypertension, and the specific treatment measures basically agree with the opinions of Dr. Li Shen and Dr. Wang Li. For the identification and treatment of this disease in Chinese medicine, the following points are emphasized: First, identification of pathology. It was clearly identified as actual evidence or deficiency evidence or mixed evidence of deficiency and reality. The patient has both Qi deficiency and Damp-Heat and Blood stasis, so it is a deficiency of the root and the symptoms. Second, identify the location of the disease. The patient’s low back pain and weakness are manifestations of kidney qi deficiency. Therefore, the deficiency is mainly in the spleen and kidney. The patient’s tongue is slightly yellowish and greasy, with bitterness in the mouth and nausea, which is due to damp-heat obstruction in the middle and stomach. Third, the results of induction and identification. Through identification and analysis, the evidence was identified as spleen-kidney qi deficiency, damp-heat internalization, and blood stasis blocking the ligaments. Fourthly, the treatment principle was established according to the results. According to the principle of “the one between goes hand in hand” and “the one even goes alone”, the TCM treatment for this patient should insist on helping the positive and eliminating the evil, and treating both the symptoms and the root cause. In terms of helping the righteous, we should emphasize tonifying the spleen and kidneys, but it is not advisable to use such pungent and hot products as cinnamon, Radix et Rhizoma, ginger, etc., so as to avoid over-warming and tonicity, which will help the evil and violate the precept of “actual reality”. In terms of eliminating evil, one is to pay attention to clearing the damp heat in the middle and lower jiao. Dr. Wang Li advocated the use of Wenzhi Tang, which has the function of regulating Qi, resolving phlegm, clearing bile and harmonizing the stomach, which is suitable for this patient, and suggested the addition of Huang Lian 6g and Plantago ovata 15g to strengthen the effect of clearing damp-heat in the middle and lower jiao. For qi deficiency and blood stasis, treatment is mainly to benefit the qi and activate the blood, agreeing with the above physicians to choose the tonic yang return five soup, the formula of astragalus with angelica, red, white peony, ground dragon and so on with more suitable for the patient’s condition.  Chief physician Li Xiuying: The above physicians have discussed this case very well, now a brief summary and supplement. The final diagnosis through clinical and pathological analysis was primary malignant hypertensive renal damage and rapidly progressive renal failure. In the diagnostic process, renal biopsy played a crucial role, without which it would have been impossible to make a definitive diagnosis in this patient, thus illustrating again the importance of renal biopsy in the diagnostic process of renal disease. The treatment of this disease should be considered in a comprehensive manner, and treatment measures include: (1) aggressive control of the primary disease. The primary disease of this patient is primary malignant hypertension, and the antihypertensive treatment agrees with the opinions of the above physicians. (2) Strict control of diet. The dietary principle is low salt, low fat, and appropriate high quality protein. (3) Delay or even reverse the progression of renal insufficiency. The main mechanism of the rapid progression of renal insufficiency due to malignant hypertension is the formation of capillary microthrombosis in the kidney and onion skin-like changes in the renal arteries. The main mechanism is the microthrombosis of kidney capillaries and onion skin-like changes of renal arteries. Dr. Zhanyongli and other doctors have done large-scale clinical observation, and it is recommended to use one or two courses of treatment. (4) Chinese medicine treatment. Although the patient is mainly suffering from deficiency, she is in the middle of deficiency, so she should not forget to eliminate the evil while helping the righteous. The main objective is to support the righteousness by tonifying the spleen and kidney. The formation of blood stasis in this patient includes “qi deficiency and blood stasis”, “long-standing disease into the complex”, “water disease and blood”, etc., rather than simple blood stasis evidence. Therefore, when invigorating the blood, Huang Qi is combined with Angelica sinensis, Chuanxiong and Dilong to nourish the blood and invigorate it. (5) Symptomatic treatment. Including correction of metabolic acidosis, renal anemia, calcium, phosphorus metabolism disorders, etc. In short, the treatment of this disease should be comprehensive and integrated. It has been reported in the literature that the 5-year kidney survival rate of primary malignant hypertension secondary to renal damage is 60%, while the 18-month kidney survival rate of chronic nephritis and other renal diseases secondary to malignant hypertension is only 4%, indicating that primary malignant hypertension is better than chronic nephritis and other secondary malignant hypertension. The patient has been clearly diagnosed with primary malignant hypertension, therefore, with active treatment, his prognosis is fair and his renal function may further improve.  3 . Postscript After discussion, the main treatment plan was re-established as follows: (1) 1 dose of Chinese herbal medicine per day to benefit Qi, invigorate blood, and clear heat and dampness. (2) Intravenous drip of Chinese herbal medicine. Thromboxone injection 10ml into 5% glucose solution 250ml, intravenous drip, once a day, 2 weeks as a course of treatment. (3) Chinese herbal medicine enema. Prescription: 30g of raw rhubarb, 15g of gong ying, 30g of calcined keel, 30g of calcined oyster, 150ml of decoction water, and enema once a night. (4) Anti-hypertensive treatment. Nifedipine extended-release tablets 20mg, 3 times daily, metoprolol tartrate 12.5mg, 2 times daily. (5) Other symptomatic treatment was maintained at the time of admission. 4 weeks later, symptoms such as dizziness and nausea improved significantly. Blood pressure was measured at 130/84 mmHg. blood creatinine was rechecked at 177µmmol/L, creatinine clearance at 33.5 ml/min, urea nitrogen at 10.7 mmol/L, total serum protein at 53 g/L, albumin at 32 g/L, 24-hour urine protein quantification at 0.52 g. He was discharged from the hospital on December 3, 2003, and was followed up regularly at the outpatient clinic. on February 3, 2004 Outpatient check blood pressure 132/82mmHg, blood creatinine 179µmmol/L, creatinine clearance 34.1ml/min, urea nitrogen 11.1mmol/L, total serum protein 54g/L, albumin 33g/L, 24-hour urine protein quantification 0.49 g, stable condition.

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