Malignant And Renal Vascular Hypertension

This is a subject very near and dear to my heart - literally! I have never had hypertension (high blood pressure) in my entire life, even during pregnancies and suddenly this past summer, I found myself faced with the horrifying diagnosis of not only hypertension but malignant hypertension.

Malignant hypertension is high blood pressure that basically comes from out of nowhere and is extremely high (systolics of 130 or greater). There can be heralding symptoms, however, in my case, by the time I was aware of my blood pressure numbers, they were far beyond 'a little elevated'.

The most horrifying aspect of this ordeal to me was that I did not realize that I had become hypertensive until it was a crisis, and secondly, I did not receive proper medical treatment at the outset. Please read and be aware of this medical condition as it can cost you your kidney health if not your life by going untreated.

The only hallmark symptom that I can truly say I had at the outset of this illness that spanned over a month before it got resolved was overwhelming fatigue. Since I am a high energy kind of person, that in itself was a bit distressing. However, finally, I ended up with severe abdominal pains which happened to me on 2 separate occasions and thinking I had appendicitis, I went to the emergency room the second time. However, even at the ER, my blood pressure was not noted to be markedly elevated.

On going to my physician for the usual followup after an ER visit, my blood pressure was 180/130, much to my surprise, and my kidney functions and potassium were also off. Since I had never had a history of any of this, it was quite alarming. Even though I was 55 years old, to come on so suddenly was quite unnerving. I also by then had developed a horrible headache which I was unable to shake and the fatigue was rearing its head constantly.

Since I usually have LOW blood pressures, I was not a tad bit alarmed. My provider, who I thought was a very reputable physician assistant, proceeded to diagnose my hypertension as simple hypertension and she made the erroneous assumption that this was due to stress. When I pressed her about how absurd that was in connection with this particular patient, she basically brushed any other possibility aside. She gave me samples of medications, told me to quit being so stressed, and let me walk out of the office with a blood pressure that should have been medically treated urgently.

To shorten a very long and exasperating story, I spent the next week being flipped and flopped from one ineffective medication to another, all of which I reacted to with worsening headaches, incredibly high blood pressures and overwhelming fatigue. Now if I wasn't stressed before, this definitely was doing it! As well, I had the added benefit of leg swelling to enormous proportions - still being told that I was too stressed and that was the cause of all of this.

By profession, I am a medical transcriptionist, and since I know symptoms, I broached the subject one afternoon to her that perhaps this was being caused by 'something else' such as renal vascular hypertension only to get my words thrown back in my face on the order of 'don't you think you are jumping the gun here a bit?'

At the end of that week of agony, I finally ended up in the ER because I had a headache that was totally out of control. I could not work, I could not sleep, and I was definitely beyond 'stressed'. My blood pressure was STILL sky high as well after all these medications but they sent me home after administering pain medication and giving me more to take so that I was knocked out.

'Enough is enough' could not have been truer. I finally decided that if I did not get help and get it soon, I would be in serious medical shape so I took it upon myself to get myself to an internal medicine physician.  The end of the story is that after many tests, it was discovered that in fact I did not have hypertension related to stress and that I had been misdiagnosed as well as mistreated.

The term 'malignant hypertension' means that this is a sudden, rapid development and results in extremely high blood pressures. This affects about 1% of people with hypertension but it is something that is a medical emergency. Although I did not have many of these symptoms, I did have some of them but was feeling so poorly that I did not realize what I had.

• Chest pain, mid chest or crushing/pressure (this can lead to a heart attack)
• Cough
• Headache (this finally did develop - it was the worst of my life and unrelenting)
• Blurred vision
• Abnormal sensation or numbness - arms, legs, face or other areas
• Changes in mental status such as restlessness, anxiety, decreased alertness or ability to concentrate, sleepiness, confusion and fatigue (I had the overwhelming fatigue and sleepiness for no explainable reason)
• Decreased urine output (this is an indication of kidney damage)
• Nausea or vomiting
• Seizure
• Shortness of breath
• Weakness of arms, legs, face or other areas

The other symptom that I had in spades was that when I had the headache, it was so severe that it would wake me from sleep and if I got up out of bed, it would disappear or lessen for a time, usually 20 or 30 minutes later.  This is an indicator of malignant hypertensive headache.

1. Brain damage from coma
2. Seizures
3. Mentation changes (encephalopathy)
4. Intracerebral hemorrhage (bleed on the brain)
5. Constriction or spasming of the arteries in the brain
6. Stroke
7. Swelling
8. Heart attack
9. Chest pain due to weakened heart muscle
10. Abnormal rhythm of the heart
11. Kidney failure
12. Lung edema which in turn can lead to congestive heart failure
13. Permanent blindness

Again, if you suspect you have the malignant variety of hypertension or even if your blood pressure is abnormally elevated, seek medical attention immediately as it is better to be safe than sorry.

We have invested in a simple blood pressure cuff as well so that periodically we can monitor our own blood pressures on a weekly basis - in the event of high values on a more frequent basis. For the price of the monitor, it has been well worth it so that I will never be caught unaware again.

For renal vascular hypertension, the key is to keep those scheduled checkups for performance of labs and/or any imaging studies that need to be done and monitoring your blood pressure on a regular basis and keeping track of the numbers.

As a result of the malignant hypertension and after having numerous blood tests, it was recommended that I have an MRI of my kidneys and also an MR angiogram of my renal arteries to see if this was the culprit causing the spikes in blood pressure. Sure enough, that was my doctor's #1 theory and it proved to be true. I had greater than 50% narrowing of not one renal artery but both renal arteries, which again, can cause malignant hypertension. If untreated, this condition can also cause kidney death because it means your kidneys are receiving decreased circulation and eventually stop functioning.

Fortunately for me, I discovered the inappropriateness of the treatment that I was receiving early on. I can only be thankful that I reacted to all the medications my PA-C had given me because if the hypertension had just 'settled down' nothing ever would have been discovered until it was perhaps too late and irreparable damage could have been done. By finding the cause of the hypertension, I was scheduled right away and had balloon angioplasties of both renal arteries which opened them up instantly though it does take some time for normal flow to be restored.

What causes this? According to the literature, renal vascular hypertension is most often caused by fibromuscular dysplasia, which is usually a genetic condition. In women, unfortunately it is almost always bilateral. In men, it usually occurs to one side or the other. It also is much more frequent in women than in men. It also can be caused by high cholesterol which then affects your arteries.  In my case, since my cholesterol is normal, it was not caused by cholesterol plaque but instead by this entity of fibromuscular dysplasia.

My distress, however, comes in knowing the millions of people in this country who are diagnosed with hypertension every day and the multitude of medications that are thrown at all of us. I'm wondering how many providers take the time to rule out renal vascular hypertension or fibromuscular dysplasia.

Had the angioplasty and ballooning not worked on my kidney arteries, I would have had to have stents placed in the arteries to keep them open to blood flow. I feel so very fortunate that I caught this in time and that by all appearances no serious damage was done. I have been able to also wean down my blood pressure medicine to the smallest possible dose and may be able to be off it completely within the next month or so. However, I will have to be checked now every 3 months throughout my lifetime to make sure that the blood flow is still appropriate and that my kidney functions are normal. I say though - a very small price to pay for one's health!

If you have any worries about the possibility of malignant hypertension or renal vascular hypertension as a cause for high blood pressure, these are some of the tests that can be performed to diagnose it.

• Blood test of BUN and creatinine - mine were abnormal
• Arterial blood gas
• Urinalysis (casts in the urine show kidney damage)
• Chest x-ray can show an enlarged heart or congestion
• Blood test of aldosterone (mine was abnormal)
• Cardiac enzymes (these are markers for heart damage)
• Blood test for renin (mine was abnormal)
• Electrocardiogram
• Renal ultrasound though the standard now is for an MRI or MR angiogram of the kidneys