Metabolic alkalosis and induced hypokalaemia in the diagnosis of renovascular arterial hypertension
Alcalosis metabólica e hipopotasemia inducida en el diagnóstico de hipertensión arterial vasculo-renal.
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The patient is referred for external consultation to test for chronic renal failure with creatinine 1.56mg/dl (ClCr by MDRD 48ml/min.) No significant nephrourologic antecedents.</p><p class="elsevierStylePara">Physical examination showed right carotid murmur, weak popliteal pulse and lack of tibial and dorsalis pedis pulses as pathological findings. The blood count showed normocytic-normochromic anaemia (Hb 10.4mg/dl; MCV 91fl; MCH 30.6pg; and MCHC 31g/dl.) In the plasma biochemistry, potassium was 3.7mEq/l. Venous blood gas tests found plasma alkalaemia (pH 7.461) due to metabolic alkalosis (CO3H 29.5mEq/l), with adequate respiratory compensation (pCO2 measured 42.3mmHg, with PCO2 estimated at 43.85 ± 2mmHg.) Ultrasound showed kidneys of normal aspect and size.</p><p class="elsevierStylePara">The presence of generalised vascular disease, ATHN and metabolic alkalosis, which was inadequate for the patient’s level of renal function, led to the suspicion of the presence of renovascular AHTN. A renal arteriography was  requested previous infusion of 2000cc of 0.9% saline serum in 24 hours (to prevent contrast-induced nephropathy), leading to hypokalaemia (2.9meq/l) with no electrocardiographic changes.</p><p class="elsevierStylePara">The arteriography detected stenosis in both renal arteries (figure 1), which was corrected with angioplasty and stent.</p><p class="elsevierStylePara">Renovascular arterial hypertension is one of the most common causes of secondary arterial hypertension and early diagnosis is important since it is a potentially reversible disorder. The incidence of this disorder is lower than 1% in patients with slight AHTN.<span class="elsevierStyleSup">1</span> However it is between 10-45% in serious or malignant AHTN.<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">The presence of AHTN, metabolic alkalosis and hypokalaemia should lead to the suspicion of the existence of an excess of mineralocorticoids.<span class="elsevierStyleSup">3</span> In such cases, hypokalaemia only appears in 50% of cases,<span class="elsevierStyleSup">4</span> but it may be shown by the administration of sodium and water either with oral sodium chloride for three days (urinary sodium > 200mEq/24 hours to verify adequate overload)<span class="elsevierStyleSup">6</span> or 2 litres of isotonic solution for four hours,<span class="elsevierStyleSup">7</span> controlling arterial hypertension and hypokalaemia if present, and evaluating the risks of sodium overload. Increased distal flow and hyperaldosteronism increased the elimination of potassium.<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">The elimination of alderosterone in urine > 14μg/24 hours<span class="elsevierStyleSup">6</span> and the concentration of plasma alderosterone > 10ng/dl<span class="elsevierStyleSup">7</span> will confirm the diagnosis.</p><p class="elsevierStylePara">The correct interpretation of simple diagnosis tests, such as venous blood gas in a proper clinical context and the provocation of hypokalaemia with the administration of sodium, very suggestive of hyperstimulation of the renin-angiotensin-aldosterone system are very useful in diagnosing patients with renovascular arterial hypertension.</p><p class="elsevierStylePara"><a href="grande/24218078_f1_p91.jpg" class="elsevierStyleCrossRefs"><img src="24218078_f1_p91.jpg"></img></a></p><p class="elsevierStylePara">Figure 1. </p>" "pdfFichero" => "P-E-S-A242-EN.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "24218078_f1_p91.jpg" "Alto" => 407 "Ancho" => 259 "Tamanyo" => 17794 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Lewin, A, Blaufox, MD, Castle, H, et al. Apparent prevalence of curable hypertension in Hypertension Detection and Follow-up Program. Arch Intern Med 1985;145:424. <a href="http://www.ncbi.nlm.nih.gov/pubmed/3872106" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Mann, SJ, Pickering, TG. Detection of renovascular hypertension. State of the art: 1992. Ann Intern Med 1992;117:845." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Stewart, PM. Mineralocorticoid hypertension. Lancet 1999;353:1341. <a href="http://www.ncbi.nlm.nih.gov/pubmed/10218547" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Mulatero, P, Stowasser, M, Loh, KC, et al. Increased diagnosis of primary aldosteronism, including surgically correctable forms, in centers from five continents. J Clin Endocrinol Metab 2004;89:1045. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15001583" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Young, DB. Quantitative analysis of aldosterone¿s role in potassium regulation. Am J Physiol 1988;255:F811. <a href="http://www.ncbi.nlm.nih.gov/pubmed/3414827" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Young, WF Jr. Primary aldosteronism: A common and curable form of hypertension. Cardiol Rev 1999;7:207. <a href="http://www.ncbi.nlm.nih.gov/pubmed/10423672" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Holland OB, Brown H, Kuhnert L, et al. Further evaluation of saline infusion for the diagnosis of primary aldosteronism. Hypertension 1984;6:717. <a href="http://www.ncbi.nlm.nih.gov/pubmed/6389337" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000002900000001/v0_201502091632/X2013251409005268/v0_201502091633/en/main.assets" "Apartado" => array:4 [ "identificador" => "35436" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000002900000001/v0_201502091632/X2013251409005268/v0_201502091633/en/P-E-S-A242-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251409005268?idApp=UINPBA000064" ]
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