Hyponatremic hypertensive syndrome secondary to renal. Renovascular hypertension renal artery stenosis hyponatremic hypertensive syndrome abnormal. In this article, we discuss the pathophysiology, diagnosis, differential diagnosis, and management of hyponatremia and hepatorenal syndrome in patients with cirrhosis. Cases with critical unilateral renal artery stenosis manifesting with the hyponatremic hypertensive syndrome are rare and a comprehensive description of this disorder in the pediatric population is lacking in the literature. Clinical practice guideline on diagnosis and treatment of. It is recognized by the association of the clinical signs and symptoms of hyponatremia and hypertension.
Physical examination will likely include skin turgor test to check for dehydration, checking for edema and neurological examination. The hyponatremic hypertensive syndrome in a preterm infant ncbi. Accelerated hypertension with hyponatremia and hypokalaemia. Two young children with renal artery stenosis and severe hypertension who presented with the socalled hyponatremic hypertensive syndrome hhs, with marked urine and solute loss during the acute phase, are described. The most common underlying cause of hyponatremic hypertensive syndrome in adults is severe atherosclerotic renovascular disorder while in children the most common cause of hyponatremic hypertensive syndrome is unilateral congenital renal artery stenosis due to some form of arterial. Hyponatremichypertensive syndrome with renal ischemia. Making an accurate differential diagnosis is important both therapeutically and prognostically. However, hypertension is a major risk factor for heart disease, stroke, kidney failure, and eye problems. Hyponatremic hypertensive syndrome hhs is of special concern in patients with both hyponatremia and renovascular hypertension. Hyponatremic hypertensive syndrome secondary to renal ischemia. Export all images to powerpoint file add to my favorites. Hyponatremic hypertensive syndrome associated with renovascular hypertension a case report yayoi tsukada tetsuou 1, yoshiko yamazaki miyatake 1, kunio tanaka 1, takeshi suzuki 1, fumio ohtsu 1, koichi nagasawa 1, masahiro fujii 2, shigeo tanaka 2, yasuhiko iino 3, koichi tamura 4.
Hiponatremikhipertansif sendrom hyponatremic hypertensive syndrome 2 introduction hyponatremic hypertensive syndrome hhs is a condition characterized by severe hypertension, hyponatremia or hypochloremia caused by unilateral renal artery stenosis or occlusion 1. It is a rare, but serious complication of unilateral renal stenosis characterized by resistant hypertension and profound natriuresis. The hyponatremic hypertensive syndrome and proteinuria promptly responded to treatment with angiotensinconverting enzyme inhibitors, suggesting an angiotensin ii dependency of these disorders. Hyponatremic hypertensive syndrome, pediatric nephrology. It can rarely develop due to antiphospholipid syndrome aps.
Hyponatremic hypertensive syndrome hhs is characterized by hyponatremia, severe hypertension, polyuria and polydipsia in association with unilateral renal artery stenosis 24. In children, 525% of the cases with secondary hypertension are. Pdf hyponatremic hypertensive syndrome in pediatric. The lowsodium syndrome or, less specifically, the low salt syndrome. Hhs has been typically reported in the elderly, asthenic females with underlying renal artery atherosclerosis, but is underreported in the pediatric population 5, 6. Unilateral renal artery stenosis presented with hyponatremic. Severe polyuria and polydipsia in hyponatremic hypertensive syndrome associated with wilms tumor. Any of the following conditions can lead to hyponatremia. Malignant hypertension as a presentation has been reported in adults with hhs but is rare in children.
We aimed to increase awareness of early diagnosis of hhs among polyuric, hypertensive and hyponatremic children in order to prevent renal damage and lifethreatening complications. Renal artery stenosis is one of the secondary causes of pediatric hypertension. Hypertensive emergency is a lifethreatening condition that requires immediate evaluation and treatment. The hyponatremic hypertensive syndrome is a rare but serious complication of renovascular disease. The combination of hyponatremia and renovascular hypertension is called hyponatremic hypertensive syndrome hhs. Hyponatremic hypertensive syndrome associated with. Faced with the revelatory pattern of accelerated hypertension with hyponatremia and hypokalaemia, the authors might have suspected acute renal ischemia due to critical renal artery stenosis, renal artery. Hyponatremic hypertensive syndrome a retrospective.
Hyponatremic hypertensive syndrome, a disorder of severe hypertension and hyponatremia, could result from any causes of high renin. Fancony syndrome bartter syndrome renal concentrating defect renal structure and function normal nephrogenic. Hyponatremic hypertensive syndrome hhs is an uncommon disorder, in which hypertension is associated with profound hyponatremia. Hyponatremichypertensive syndrome in an 18monthold. Drinking too much water or receiving too much fluid through an iv.
The hyponatremic hypertensive syndrome in renal artery. Discussion renovascular hypertension is the most common type of secondary hypertension and a variety of symptoms are. Hypertension usually has no symptoms, and many affected individuals do not know they have the condition. Pdf severe polyuria and polydipsia in hyponatremic. Smith neurocritical care society 2012 abstract sustained intracranial hypertension and acute brain herniation are brain codes, signifying. Hyponatremic hypertensive syndrome in pediatric patients. In 1965, brown and colleagues named the combination of hyponatremia caused by renal sodium loss and severe hypertension the hyponatremic hypertensive syndrome hhs 5. We report on a 4yearold girl with hyponatremichypertensive syndrome hhs, a rare entity in childhood. The hyponatremic syndrome is a prevalent phenomenon, according to recent reports, perhaps largely owing to the facility with which sodium determinations have been able to be performed by the flame photometer in the last decade. In children, severe hypertension can be caused by a variety of different underlying conditions.
The hyponatremichypertensive syndrome in patients with renal ischemia is not rare. Hyponatremichypertensive syndrome with extensive and. Hyponatremic hypertensive syndrome hhs is characterized by hypertensive. Angiotensinconverting enzyme inhibition ameliorates the. It tends to affect elderly asthenic women who smoke heavily. Pdf unilateral renal artery stenosis presented with hyponatremic. In recent years, a low sodium concentration has been found frequently to accompany a wide variety of disease states.
The hyponatremic hypertensive syndrome hhs was firstly described in pediatric patients. A doctor will probably ask you about water intake, medications, recent changes in the body weight and underlying chronic diseases. Hyponatremichypertensive syndrome in an 18monthold male. We report a patient with uncontrolled hypertension and severe hyponatremia. Stimulation of renin release from the ischemic kidney is probably central to the pathophysiology. Hyponatremic hypertensive syndrome a retrospective cohort study. Hyponatremic hypertensive syndrome hhs in an 18month.
The combination of hyponatremia and renovascular hypertension is called the hyponatremic hypertensive syndrome hhs 14. When blood pressure is elevated, the heart and arteries have to work harder than normal to pump blood through the body. Renovascular hypertension can occur secondary to renal artery stenosis which can sometime present as hyponatremic hypertensive syndrome hhs. The majority of patients reported have been elderly, asthenic females, and in most the underlying renal artery pathology was atherosclerosis 5. Hyponatremic hypertensive syndrome hhs is an uncommon disorder usually encountered in the adult population with unilateral renal artery stenosis and is underrecognized in the pediatric population. The girl was referred to us from a local hospital with a history of recurrent fever, vomiting, and seizures. Many medical illnesses, such as congestive heart failure, liver failure, renal failure, or pneumonia, may be associated with hyponatremia. Hyponatremic hypertensive syndrome hhs is characterized by hypertensive crisis, and hyponatremia secondary to unilateral renal damage with glomerular and tubular dysfunction. Renal artery stenosis precipitates hyponatremic hypertensive. Hyponatremia causes, symptoms, signs, workup, treatment.
Most of the individual causes of hyponatremia are discussed in detail separately, as are issues related to the diagnosis and treatment of hyponatremia algorithm 1 and algorithm 2. Initial investigations revealed severe hyponatremia serum na 120 mmoll, hypochloremia serum cl 68 mmoll, and mild hypokalemia. Both children also presented with severe high molecular proteinuria, glycosuria, and hypercalciuria, only the first symptom. Rarity of hyponatremic hypertensive syndrome in children may project its underrecognition.
Mcareavey and colleagues 14 in glasgow noted hyponatremia plasma sodium renovascular hypertension. An eighteen monthold male presented with drowsiness, sudden onset status epilepticus and blood pressure of 210160. Chronic hyponatraemia without severe or moderately severe symptoms 3. The term hyponatremic syndrome implies that there are clinical signs and symptoms which are rather specifically related to a low sodium concentration in the serum and extracellular fluid. Despite activation of renin angiotensin axis secondary to renal artery stenosis, these groups of children have significant hyponatremia. An overview of the causes of hypotonic hyponatremia is presented in this topic.
Hyponatremic hypertensive syndrome is a rare condition of renovascular hypertension characterized by electrolyte abnormalities hyponatremia, hypokalemia, polyuria, and high renin activity. Elevated plasma levels of renin in most cases suggest that the stimulation of renin release from the ischemic kidney plays an important pathophysiologic role. After removal of the leiomyosarcoma, plasma concentration of active renin, but not of prorenin, normalized and the. Hyponatremic hypertensive syndrome hhs is rare and is characterized with hypertension together with hyponatremia, hypokalemia and low plasma osmolarity and considered to be based on renal ischemia. On the contrary, accelerated hypertension is a consensual indication to screen for renovascular hypertension 4. Stephen huff josh duckworth alexander papangelou scott d. Hyponatremic hypertensive syndrome 299 circulation journal vol. The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure iii chair aram v. The hyponatremic hypertensive syndrome hhs was firstly described in pediatric patient. Hyponatremic syndrome jama internal medicine jama network. Pam stainpositive particles, indicative of renin granules, were found in the cells of the apparatus fig4b. Intense and prolonged exercise that causes excessive sweating. Patients with syndrome of inappropriate antidiuresis 14 3.
England health, syndrome is characterized by hypertension and profound natriuresis, leading to body sodium and water depletion. Although hypertensive emergencies can lead to significant morbidity and potentially fatal targetorgan damage, only 1%3% of patients with hypertension will have a hypertensive emergency during their lifetime deshmukh 2011. Lab work revealed hyponatremia, hypokalemia, and elevated peripheral renin. In evaluating a neonate with hyponatremia and hypertension, hhs should be considered, especially in case of umbilical arterial catheterization. It is mostly encountered in adults with unilateral renal artery stenosis. The most common underlying cause of hyponatremic hypertensive syndrome in adults is severe atherosclerotic renovascular disorder while in children the most common cause of hyponatremic hypertensive syndrome is unilateral congenital renal.
Detection of white coat hypertension or masked hypertension in patients not on drug therapy. We describe a 4yearold boy who presented with severe hypertension, profound. Hiponatremikhipertansif sendrom hyponatremichypertensive syndrome 2 introduction hyponatremic hypertensive syndrome hhs is a condition characterized by severe hypertension, hyponatremia or hypochloremia caused by unilateral renal artery stenosis or occlusion 1. Case records from patients in one city population 350 000 presenting between 1980 and 1997 with hypertension, hyponatremia, and evidence of renal ischemia. What to do in case hyponatraemia is corrected too rapidly. Hyponatremia is defined as a serum sodium level of less than 5 meql and is considered severe when the serum level is below 125 meql. Although renovascular hypertension is one of the commonest causes for severe hypertension in children, hhs is rarely reported in childhood.