Tumor de células yuxtaglomerulares (reninoma) como causa de hipertensión arterial en la adolescencia. A propósito de un caso / Juxtaglomerular cell tumor (reninoma) as a cause of arterial hypertension in adolescents. A case report

La hipertensión arterial (HTA) grave en pediatría responde fundamentalmente a causas secundarias. Presentamos una paciente adolescente de 14 años con HTA grave, alcalosis metabólica e hipopotasemia, secundaria a un tumor de células yuxtaglomerulares productor de renina, diagnosticado luego de dos años de evolución de HTA.

Severe arterial hypertension (HTN) in pediatrics is mainly due to secondary causes. Here we describe the case of a 14-year-old female adolescent with severe HTN, metabolic alkalosis, and hypokalemia, secondary to a renin-secreting juxtaglomerular cell tumor diagnosed after 2 years of HTN progression.

Juxtaglomerular cell tumor (reninoma) as a cause of arterial hypertension in adolescents. A case report. / Tumor de células yuxtaglomerulares (reninoma) como causa de hipertensión arterial en la adolescencia. A propósito de un caso.

Severe arterial hypertension (HTN) in pediatrics is mainly due to secondary causes. Here we describe the case of a 14-year-old female adolescent with severe HTN, metabolic alkalosis, and hypokalemia, secondary to a renin-secreting juxtaglomerular cell tumor diagnosed after 2 years of HTN progression.

La hipertensión arterial (HTA) grave en pediatría responde fundamentalmente a causas secundarias. Presentamos una paciente adolescente de 14 años con HTA grave, alcalosis metabólica e hipopotasemia, secundaria a un tumor de células yuxtaglomerulares productor de renina, diagnosticado luego de dos años de evolución de HTA.

Nephron-sparing surgery for treatment of reninoma: a rare renin secreting tumor causing secondary hypertension.

MAIN FINDINGS: A 25-year-old hypertensive female patient was referred to our institution. Initial workup exams demonstrated a 2.8 cm cortical lower pole tumor in the right kidney. She underwent laparoscopic partial nephrectomy without complications. Histopathologic examination revealed a rare juxtaglomerular cell tumor known as reninoma. After surgery, she recovered uneventfully and all medications were withdrawn. Case hypothesis: Secondary arterial hypertension is a matter of great interest to urologists and nephrologists. Renovascular hypertension, primary hyperadosteronism and pheocromocytoma are potential diagnosis that must not be forgotten and should be excluded. Although rare, chronic pyelonephritis and renal tumors as rennin-producing tumors, nephroblastoma, hypernephroma, and renal cell carcinoma might also induce hypertension and should be in the diagnostic list of clinicians. Promising future implications: Approximately 5% of patients with high blood pressure have specific causes and medical investigation may usually identify such patients. Furthermore, these patients can be successfully treated and cured, most times by minimally invasive techniques. This interesting case might expand knowledge of physicians and aid better diagnostic care in future medical practice.

Nephron-sparing surgery for treatment of reninoma: a rare renin secreting tumor causing secondary hypertension

Main findings A 25-year-old hypertensive female patient was referred to our institution. Initial workup exams demonstrated a 2.8 cm cortical lower pole tumor in the right kidney. She underwent laparoscopic partial nephrectomy without complications. Histopathologic examination revealed a rare juxtaglomerular cell tumor known as reninoma. After surgery, she recovered uneventfully and all medications were withdrawn. Case hypothesis Secondary arterial hypertension is a matter of great interest to urologists and nephrologists. Renovascular hypertension, primary hyperadosteronism and pheocromocytoma are potential diagnosis that must not be forgotten and should be excluded. Although rare, chronic pyelonephritis and renal tumors as rennin-producing tumors, nephroblastoma, hypernephroma, and renal cell carcinoma might also induce hypertension and should be in the diagnostic list of clinicians. Promising future implications Approximately 5% of patients with high blood pressure have specific causes and medical investigation may usually identify such patients. Furthermore, these patients can be successfully treated and cured, most times by minimally invasive techniques. This interesting case might expand knowledge of physicians and aid better diagnostic care in future medical practice. .

Electron microscopic evaluation of the secretory mechanisms of renin from juxtaglomerular cells / Evaluación con microscopía electrónica de los mecanismos secretorios de renina desde las células juxtaglomerulares

Although the structure and the functions of juxtaglomerular cells (JG) have been well defined, there is still a controversy about the secretory mechanisms of renin from these cells. It has been assumed that exocytosis is the main secretory mechanism in these cells in many studies, while others suggest that secretion occurs in a quite different way in these cells. There are several studies suggesting that diacrine secretion, which is very difficult to visualize, might be the other mechanism for secretion of renin. This study is an attempt to find the answers of these questions by identifying the fine structural features of the secretory granules in juxtaglomerular cells. Cyclosporin A (CyA) has been used in the current experimental study since it has already been reported that this drug increases the number of JG cells and stimulates secretion of Renin. Twelve female Sprague-Dawley rats had daily intraperitoneal injections of CyA for ten weeks. Tissue specimens from the kidneys of these animals were examined by electron microscopy. Fine structural characteristics of the secretory granules of juxtaglomerular cells have been examined. Considerable amount of granules, which goes to the exocytotic process, have been observed. Additionally, several cells, which their granules had been secreting their contents in a different way, were found. This was interpreted as the secretion type of diacrine secretion. In conclusion, this in vivo study presents morphologic evidences demonstrating that both exocytosis and diacrine secretion might occur in JG cells. We also had a chance to observe secretory granule probably exhibiting "diacrine secretion", which is very difficult to visualize, at electron microscope level for the first time. This report also provides morphologic proof which shows that these two distinct secretory mechanisms might occur simultaneously in the same juxtaglomerular cell.

Aunque la estructura y las funciones de las células yuxtaglomerulares (JG) han sido bien definidas, todavía existe controversia acerca de los mecanismos de secreción de renina en estas células. Se ha supuesto, en muchos estudios, que la exocitosis es el principal mecanismo de secreción de estas células, mientras que otros autores sugieren que la secreción se produce de una manera muy diferente en estas células. Hay varios estudios que plantean que la secreción diacrina, que es muy difícil de visualizar, podría ser otro mecanismo para la secreción de renina. Este estudio tiene como objetivo encontrar las respuestas a estas interrogantes mediante la identificación de las características estructurales de la secreción de gránulos en las células yuxtaglomerulares. Ciclosporina A (CyA) se ha utilizado en el estudio experimental actual, debido a que se ha informado que este medicamento aumenta el número de células JG y estimula la secreción de renina. Doce ratas hembras Sprague-Dawley fueron diariamente inyectadas por vía intraperitoneal, con CyA durante diez semanas. Las muestras de tejido renal de estos animales fueron examinadas a través de microscopía electrónica. Detalladas características estructurales han sido examinadas en los gránulos secretores de las células yuxtaglomerulares. Se ha observado una cantidad considerable de gránulos, que va con el proceso de exocitosis. Además, se encontaron células que habían secretado el contenido de sus gránulos de manera diferente. Esto fue interpretado como secreción de tipo diacrina. En conclusión, este estudio in vivo presenta evidencias morfológicas que demuestran que tanto la exocitosis y la secreción diacrina podría ocurrir en células JG. También tuvimos la oportunidad de observar probables gránulos secretores, que mostrarían "la secreción diacrina", que es muy difícil de visualizar, a nivel de microscopía electrónica. Este informe también proporciona la prueba morfológica que demuestra que estos dos mecanismos...

Malignant hypertension with intestinal ischemia secondary to juxtaglomerular cell tumor.

Malignant hypertension is a well-defined condition associated with high blood pressure and acute target-organ damage. Although 95% of cases are secondary to essential hypertension, its etiological profile is broad. Juxtaglomerular cell tumor is a rare condition, with only approximately 65 cases reported to date. We describe a patient with malignant hypertension with acute renal failure and intestinal ischemia secondary to a juxtaglomerular cell tumor. We believe this is the first case of juxtaglomerular cell tumor causing malignant hypertension. The diagnostic approach and treatment are discussed.

Juxtaglomerular cell tumor as a rare cause of hypertension in adults

The juxtaglomerular cell tumor is a cause of secondary hypertension in adults. A 35-year-old female patient suffering from hypertension and low serum potassium had a 3 x 3 cm solid mass at the lower pole of left kidney diagnosed by abdominal sonography. Partial nephrectomy was performed and the postoperatory was uneventful. Normalization of blood pressure was observed within the first month.

Juxtaglomerular cell tumor as a rare cause of hypertension in adults.

The juxtaglomerular cell tumor is a cause of secondary hypertension in adults. A 35-year-old female patient suffering from hypertension and low serum potassium had a 3 x 3 cm solid mass at the lower pole of left kidney diagnosed by abdominal sonography. Partial nephrectomy was performed and the postoperatory was uneventful. Normalization of blood pressure was observed within the first month.

Mecanismos de daño renal en la hipertensión arterial / Mechanisms of renal damage in the hipertension

El riñón es un órgano orientado a preservar la homeostasis del medio interno a través de mantener el balance de sodio y agua. La función del aparato yuxtaglomerular es mantener el balance glomérulo-tubular y, por consiguiente, la regulación fina de la excresión de sodio. Existe una población de hipertensos que no pueden suprimir la producción de mRNA angiotensinógeno en respuesta a una carga de sodio y por lo tanto son incapaces de mantener un balance adecuado de este ion, siendo esta una posible causa congénita de hipertensión arterial. La elevación de la presión arterial sistémica se acompaña de cambios en el riñón, como: hipertensión capilar glomerular, aumento de la presión de flujo laminar y disfunción endotelial. Como consecuencia del aumento de la permeabilidad capilar hay pasaje de macromoléculas proteicas y lipídicas al mesangio y al túbulo renal, y la AII actuando sobre las células mesangiales estimula la producción local de factor de crecimiento derivado de las plaquetas y factor de crecimiento tisular b deribado de fibroblastos induciendo un proceso cicatricial progresivo con depósito exagerado de colágeno; tanto en el mesangio glomerular, como en el intersticio glomerular, que conducen a la fase final del daño glomerular que es la esclerosis total con pérdida de la arquitectura renal y reemplazo del tejido funcionante por fibrosis. Los inhibidores ECA, antagonistas de la AII, y algunos bloqueadores de calcio, al normalizar la dinámica glomerular y la presión arterial sistémica ejercen un efecto nefroprotector que los convierte en las drogas de elección para el manejo de la hipertensión arterial.

Functional and morphometric evaluation of offspring kidney after intrauterine undernutrition.

Pregnant rats were subjected to 50% food restriction during the first or the second half of pregnancy, or throughout pregnancy. The effects of intrauterine food restriction, on kidney function and morphometry were studied in newborn and adult (3 months) offspring. No differences in glomerular diameter were observed in newborn restricted rats compared with controls. The number of glomeruli was significantly lower both in newborn and 3-month-old restricted rats. However, glomerular diameter was increased in 3-month-old rats, which suggests that hypertrophic stimuli were present. The medulla/cortex ratio increased in adult rats submitted to food restriction during pregnancy, a finding that agrees with the preserved sodium and acid excretion, and the normal osmolar and free water clearance observed in these groups. These results show that the reduction in glomerular number is still present 3 months after birth in the progeny of mothers submitted to severe food restriction during pregnancy, suggesting impairment of glomerulogenesis even after birth. Intra utero undernutrition can be regarded as an experimental model of glomerular hypertrophy.

Use of calcium excretion values to distinguish two forms of primary renal tubular hypokalemic alkalosis: Bartter and Gitelman syndromes.

Clinical or biochemical findings were reevaluated in 34 pediatric patients with primary renal tubular hypokalemic metabolic alkalosis. The patients were subdivided into two groups. Bartter syndrome (primary renal tubular hypokalemic metabolic alkalosis with normocalciuria or hypercalciuria) was diagnosed in 18 patients with molar urinary calcium/creatinine ratios greater than 0.20, and Gitelman syndrome (primary renal tubular hypokalemic metabolic alkalosis with magnesium deficiency and hypocalciuria) was diagnosed in 16 patients with molar urinary calcium/creatinine ratios less than or equal to 0.20 and plasma magnesium levels less than 0.75 mmol/L. Some clinically important differences between the groups were observed. Patients with Bartter syndrome were often born after pregnancies complicated by polyhydramnios (8/18) or premature delivery (7/18) and had short stature (11/18) or polyuria, polydipsia, and a tendency to dehydration (16/18) during infancy (12/18) or before school age (18/18). Patients with Gitelman syndrome had tetanic episodes (12/16) or short stature (3/16) at school age (14/16). We conclude that the Bartter and Gitelman syndromes represent two distinct variants of primary renal tubular hypokalemic metabolic alkalosis and are easily distinguished on the basis of urinary calcium levels.

[Intracellular messengers in the regulation of renin secretion]. / Mensajeros intracelulares en la regulación de la secreción de renina.

The intracellular messengers that seem to be involved in renin secretion (RS) from juxtaglomerular cells (JG) are calcium (Ca), cyclic adenosine monophosphate (cAMP) and cyclic guanosine monophosphate (cGMP). Unlike the majority of secretory systems, an increase in intracellular Ca concentration and calmodulin and protein kinase C activation inhibit RS. The intracellular Ca concentration in JG cells can be modified if: 1) the normal mechanisms of Ca extrusion of these cells is altered; 2) the calcium output is blocked by lanthanum; 3) the function of the voltage-sensitive Ca-channels is modified; 4) uptake or liberation of Ca from endoplasmic reticulum is modified; 5) plasmatic membrane is bypassed with calcium ionophores such as A 23187. 6) JG cells are stimulated by hormones that increase Ca and activate protein kinase C such as angiotensin II, vasopressin or alpha-1 adrenergic agonists; 7) extracellular Ca concentration increases or decreases. RS is stimulated by dibutyryl cAMP, cAMP phosphodiesterase inhibitors and by hormones and agents that activate adenylate cyclase (beta adrenergic agonists, bradykinin, histamine, forskolin and ethylcarboxamide adenosine). On the contrary, RS is inhibited by hormones and agents that inhibit adenylate cyclase such as: alpha-2 adrenergic agonists, neuropeptide Y, angiotensin II and cyclohexyladenosine. Pertussis toxin increases basal RS, blocks the inhibition by agents and hormones which inhibit adenylate cyclase and potentiate the stimulation produced by beta-adrenergic agonists. In JG cells, atrial natriuretic peptide inhibits RS, increases cGMP and decreases cAMP. The increase in cGMP correlates well with the inhibition of RS.