Organ Transplantation in Hereditary Fibrinogen A α-Chain Amyloidosis: A Case Series of French Patients.

RATIONALE & OBJECTIVE: Fibrinogen A α-chain amyloidosis (AFib amyloidosis) is a form of amyloidosis resulting from mutations in the fibrinogen A α-chain gene (FGA), causing progressive kidney disease leading to kidney failure. Treatment may include kidney transplantation (KT) or liver-kidney transplantation (LKT), but it is not clear what factors should guide this decision. The aim of this study was to characterize the natural history and long-term outcomes of this disease, with and without organ transplantation, among patients with AFib amyloidosis and various FGA variants. STUDY DESIGN: Case series. SETTING & PARTICIPANTS: 32 patients with AFib amyloidosis diagnosed by genetic testing in France between 1983 and 2014, with a median follow-up of 93 (range, 4-192) months, were included. RESULTS: Median age at diagnosis was 51.5 (range, 12-77) years. Clinical presentation consisted of proteinuria (93%), hypertension (83%), and kidney failure (68%). Manifestations of kidney disease appeared on average at age 57 (range, 36-77) years in patients with the E526V variant, at age 45 (range, 12-59) years in those with the R554L variant (P<0.001), and at age 24.5 (range, 12-31) years in those with frameshift variants (P<0.001). KT was performed in 15 patients and LKT was performed in 4. In KT patients with the E526V variant, recurrence of AFib amyloidosis in the kidney graft was less common than with a non-E526V (R554L or frameshift) variant (22% vs 83%; P=0.03) and led to graft loss less frequently (33% vs 100%). Amyloid recurrence was not observed in patients after LKT. LIMITATIONS: Analyses were based on clinically available historical data. Small number of patients with non-E526V and frameshift variants. CONCLUSIONS: Our study suggests phenotypic variability in the natural history of AFib amyloidosis, depending on the FGA mutation type. KT appears to be a viable option for patients with the most common E526V variant, whereas LKT may be a preferred option for patients with frameshift variants.

Clinical and Genetic Spectrum of Bartter Syndrome Type 3.

Bartter syndrome type 3 is a clinically heterogeneous hereditary salt-losing tubulopathy caused by mutations of the chloride voltage-gated channel Kb gene (CLCNKB), which encodes the ClC-Kb chloride channel involved in NaCl reabsorption in the renal tubule. To study phenotype/genotype correlations, we performed genetic analyses by direct sequencing and multiplex ligation-dependent probe amplification and retrospectively analyzed medical charts for 115 patients with CLCNKB mutations. Functional analyses were performed in Xenopus laevis oocytes for eight missense and two nonsense mutations. We detected 60 mutations, including 27 previously unreported mutations. Among patients, 29.5% had a phenotype of ante/neonatal Bartter syndrome (polyhydramnios or diagnosis in the first month of life), 44.5% had classic Bartter syndrome (diagnosis during childhood, hypercalciuria, and/or polyuria), and 26.0% had Gitelman-like syndrome (fortuitous discovery of hypokalemia with hypomagnesemia and/or hypocalciuria in childhood or adulthood). Nine of the ten mutations expressed in vitro decreased or abolished chloride conductance. Severe (large deletions, frameshift, nonsense, and essential splicing) and missense mutations resulting in poor residual conductance were associated with younger age at diagnosis. Electrolyte supplements and indomethacin were used frequently to induce catch-up growth, with few adverse effects. After a median follow-up of 8 (range, 1-41) years in 77 patients, chronic renal failure was detected in 19 patients (25%): one required hemodialysis and four underwent renal transplant. In summary, we report a genotype/phenotype correlation for Bartter syndrome type 3: complete loss-of-function mutations associated with younger age at diagnosis, and CKD was observed in all phenotypes.

Adherence to Antihypertensive Treatment and the Blood Pressure-Lowering Effects of Renal Denervation in the Renal Denervation for Hypertension (DENERHTN) Trial.

BACKGROUND: The DENERHTN trial (Renal Denervation for Hypertension) confirmed the blood pressure-lowering efficacy of renal denervation added to a standardized stepped-care antihypertensive treatment for resistant hypertension at 6 months. We report the influence of adherence to antihypertensive treatment on blood pressure control. METHODS: One hundred six patients with hypertension resistant to 4 weeks of treatment with indapamide 1.5 mg/d, ramipril 10 mg/d (or irbesartan 300 mg/d), and amlodipine 10 mg/d were randomly assigned to renal denervation plus standardized stepped-care antihypertensive treatment, or the same antihypertensive treatment alone. For standardized stepped-care antihypertensive treatment, spironolactone 25 mg/d, bisoprolol 10 mg/d, prazosin 5 mg/d, and rilmenidine 1 mg/d were sequentially added at monthly visits if home blood pressure was ≥135/85 mm Hg after randomization. We assessed adherence to antihypertensive treatment at 6 months by drug screening in urine/plasma samples from 85 patients. RESULTS: The numbers of fully adherent (20/40 versus 21/45), partially nonadherent (13/40 versus 20/45), or completely nonadherent patients (7/40 versus 4/45) to antihypertensive treatment were not different in the renal denervation and the control groups, respectively (P=0.3605). The difference in the change in daytime ambulatory systolic blood pressure from baseline to 6 months between the 2 groups was -6.7 mm Hg (P=0.0461) in fully adherent and -7.8 mm Hg (P=0.0996) in nonadherent (partially nonadherent plus completely nonadherent) patients. The between-patient variability of daytime ambulatory systolic blood pressure was greater for nonadherent than for fully adherent patients. CONCLUSIONS: In the DENERHTN trial, the prevalence of nonadherence to antihypertensive drugs at 6 months was high (≈50%) but not different in the renal denervation and control groups. Regardless of adherence to treatment, renal denervation plus standardized stepped-care antihypertensive treatment resulted in a greater decrease in blood pressure than standardized stepped-care antihypertensive treatment alone. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01570777.

[Text messaging and self-care support of hypertensive patients : first achievements]. / Text messaging et accompagnement des patients hypertendus : premiers acquis.

Text messaging applied to self-care support of hypertensive patients is a new e-health tool available via mobile phones and computers. First validated programs are just emerging. Without being a panacea intended to replace the doctors by machines they could be provide a significant reinforcement of the patient's empowerment for self-monitoring. It is now time to begin their evaluation in real life and in primary care setting.

La technique du text messaging appliquée au suivi des patients hypertendus est un nouvel outil de prise en charge accessible aux patients et consommateurs de soins via les téléphones portables et les ordinateurs. Les premiers programmes validés se font jour. Sans être une panacée destinée à remplacer les médecins par des machines, cette technique pourrait être à l'origine d'un renforcement notable de l'autonomie des patients souhaitant assurer activement leur propre suivi. Il est temps de débuter l'évaluation du text messaging en vie réelle et notamment en pratique de soins primaires.

Optimum and stepped care standardised antihypertensive treatment with or without renal denervation for resistant hypertension (DENERHTN): a multicentre, open-label, randomised controlled trial.

BACKGROUND: Conflicting blood pressure-lowering effects of catheter-based renal artery denervation have been reported in patients with resistant hypertension. We compared the ambulatory blood pressure-lowering efficacy and safety of radiofrequency-based renal denervation added to a standardised stepped-care antihypertensive treatment (SSAHT) with the same SSAHT alone in patients with resistant hypertension. METHODS: The Renal Denervation for Hypertension (DENERHTN) trial was a prospective, open-label randomised controlled trial with blinded endpoint evaluation in patients with resistant hypertension, done in 15 French tertiary care centres specialised in hypertension management. Eligible patients aged 18-75 years received indapamide 1·5 mg, ramipril 10 mg (or irbesartan 300 mg), and amlodipine 10 mg daily for 4 weeks to confirm treatment resistance by ambulatory blood pressure monitoring before randomisation. Patients were then randomly assigned (1:1) to receive either renal denervation plus an SSAHT regimen (renal denervation group) or the same SSAHT alone (control group). The randomisation sequence was generated by computer, and stratified by centres. For SSAHT, after randomisation, spironolactone 25 mg per day, bisoprolol 10 mg per day, prazosin 5 mg per day, and rilmenidine 1 mg per day were sequentially added from months two to five in both groups if home blood pressure was more than or equal to 135/85 mm Hg. The primary endpoint was the mean change in daytime systolic blood pressure from baseline to 6 months as assessed by ambulatory blood pressure monitoring. The primary endpoint was analysed blindly. The safety outcomes were the incidence of acute adverse events of the renal denervation procedure and the change in estimated glomerular filtration rate from baseline to 6 months. This trial is registered with ClinicalTrials.gov, number NCT01570777. FINDINGS: Between May 22, 2012, and Oct 14, 2013, 1416 patients were screened for eligibility, 106 of those were randomly assigned to treatment (53 patients in each group, intention-to-treat population) and 101 analysed because of patients with missing endpoints (48 in the renal denervation group, 53 in the control group, modified intention-to-treat population). The mean change in daytime ambulatory systolic blood pressure at 6 months was -15·8 mm Hg (95% CI -19·7 to -11·9) in the renal denervation group and -9·9 mm Hg (-13·6 to -6·2) in the group receiving SSAHT alone, a baseline-adjusted difference of -5·9 mm Hg (-11·3 to -0·5; p=0·0329). The number of antihypertensive drugs and drug-adherence at 6 months were similar between the two groups. Three minor renal denervation-related adverse events were noted (lumbar pain in two patients and mild groin haematoma in one patient). A mild and similar decrease in estimated glomerular filtration rate from baseline to 6 months was observed in both groups. INTERPRETATION: In patients with well defined resistant hypertension, renal denervation plus an SSAHT decreases ambulatory blood pressure more than the same SSAHT alone at 6 months. This additional blood pressure lowering effect may contribute to a reduction in cardiovascular morbidity if maintained in the long term after renal denervation. FUNDING: French Ministry of Health.

[Masked hypertension]. / L'hypertension masquée.

"Masked hypertension" is defined as high blood pressure outside the medical setting (ambulatory or self-measurement at home) and normal BP in the medical setting Masked hypertension is frequent, particularly in patients receiving antihypertensive treatment. It is often associated with other cardiovascular risk factors. The cardiovascular prognosis in terms of target organ damage and complications is poorer than that of subjects considered normotensive by all measurement methods, and similar to that of subjects considered hypertensive by all measurement methods. Its pathophysiological mechanism is unknown. No controlled trials have yet been conducted to determine the possible benefits of treatment.

Prevalence and Risk Factors for Secondary Hypertension in Young Adults.

BACKGROUND: The prevalence of secondary causes of hypertension in young adults is unknown, and therefore, there is no consensus about the indication of screening of secondary hypertension (2HTN) in this population. The objective was to report the prevalence and the causes of 2HTN in young subjects. METHODS: In this cross-sectional study, 2090 patients with confirmed hypertension aged 18 to 40 years with full workup for 2HTN screening were included. We assessed the prevalence of 2HTN and analyzed the factors associated. RESULTS: Among 2090 patients, 619 (29.6%) had a 2HTN. The most frequent diagnoses of 2HTN in descending order were primary aldosteronism (n=339; 54.8%), renovascular hypertension (n=114; 18.4%), primary kidney disease (n=80; 12.9%), pheochromocytoma/functional paraganglioma (n=37; 5.9%), hypertension caused by drugs or substances (n=32; 6.0%), and other diagnoses (n=17; 2.7%). Patients with blood pressure <160/100 mm Hg did not have a lower prevalence of 2HTN regardless of the number of treatments. The prevalence of 2HTN was higher in the decade between 30 and 40 years of age than between 18 and 30 years of age (P=0.024). Female sex, hypokalemia, treatment with at least 2 medications, no familial history of hypertension, body mass index <25 kg/m², and diabetes were associated with a higher prevalence of 2HTN. CONCLUSIONS: The prevalence of 2HTN is high among young patients with hypertension (29.6% in our cohort), regardless of age and blood pressure level. All patients with hypertension under 40 years of age should be screened for secondary causes.

[Management of resistant hypertension]. / Prise en charge d'une hypertension artérielle résistante.

High blood pressure is one of the leading factors influencing the cardiovascular risk. Despite current knowledge on the management of hypertension and the numerous antihypertensive drugs available, hypertension remains insufficiently controlled and part of these "uncontrolled" patients meet the definition of resistant hypertension. Resistant hypertension is defined by the failure of lowering blood pressure values to blood pressure target (office blood pressure < 140/90 or 130/80 mmHg in patients with diabetes or chronic kidney disease) despite appropriate treatment with optimal doses of three antihypertensive drugs from three different classes, one of which is a diuretic. Pseudoresistance should be excluded by using 24h ambulatory blood pressure or home blood pressure. The management of resistant hypertension includes the screening of secondary forms of hypertension and the identification of life style factors such as obesity, excessive alcohol and dietary sodium intake, volume overload, drug-induced hypertension. The treatment associates lifestyle changes, discontinuation of interfering substances, association of antihypertensive drugs on top of the initial triple therapy (including diuretic, blockers of the renin-angiotensin system and calcium channel blockers) ie aldosterone antagonists as fourth line treatment. New device-based approaches aiming to decrease the sympathetic tone including renal denervation and baroreceptor stimulation are under development.

Management of arterial hypertension: home blood pressure measurement is a cornerstone for telemonitoring and self-management.

The development of mobile telephones has made it possible to design blood pressure (BP) monitors with data transmission via cellular lines, contributing to the emergence of "e-health". Today, the direct-to-consumer marketing of devices create a new context allowing an algorithmic processing of information for remote decision-making either by the patient or by a healthcare professional. The home BP telemonitoring (HBPT) is the remote transmission of BP values, measured at home and transmitted to the doctor's office or hospital, by means of telehealth strategies. In this context, randomized controlled trials (RCTs) studies have demonstrated HBPT ability in improving patients' compliance and adherence to treatment and in accomplishing better hypertension control rates. The level of evidence for the drop in BP is "moderate" and the place of HBPT is not clearly established in current practice. Digital interventions have the potential to support patient in self-management. This approach presupposes the prior acquisition of skills, the level of which must be adapted to the level of health literacy of each patient. Few of medical applications (mobile apps or web-apps) for hypertension can be regarded as accurate and safe for clinical use and to date, we do not have high quality evidence to determine the overall effect of the use smartphone apps on BP control.

[Out-of-center blood pressure measurements in dialysis patients: Feasibility and comparison of methods]. / Mesures hors centre de la pression artérielle chez les hémodialysés chroniques : faisabilité et comparaison des méthodes.

The European Renal Association-European Dialysis and Transplant Association (ERA-EDTA)/European Society of Hypertension (ESH) recommends out-of-center blood pressure measurements, self-blood pressure measurement or ambulatory blood pressure measurement in dialysis patients. However, the feasibility of out-of-center blood pressure measurements in routine care is not known. The objective of our study was to quantify it as "a priori" i.e. the percentage of hemodialysis to whom out-of-center blood pressure measurements can be proposed and who accept it, as "a posteriori", i.e. the percentage of out-of-center blood pressure measurements made and valid. A systematic out-of-center blood pressure measurements program was implemented from April to October 2019 in our chronic hemodialysis structures. It was proposed to each dialysis patient to carry out after education, an self-blood pressure measurement (Omron M3®), from 2 measurements, to 1 to 2minutes interval, mornings and evenings of 6days without dialysis (validity: 15 measures). Apart from arrhythmic patients, to all patients "not eligible" for self-blood pressure measurement (visually impaired, hemiplegic, neuropsychological disorders, language barrier), a 44-hour ambulatory blood pressure measurement (Microlife WatchBP 03®) was proposed separating 2 hemodialysis sessions; measures every 15minutes from 7 a.m. to 10 p.m. and 30minutes from 10 p.m. to 7 a.m. (validity: 40 measurements/day and 14/night). This is a study evaluating practices recommended for routine care in 18-year-old hemodialysis, having given their consent to the collection and analysis of the data. One hundred twenty nine patients were treated with chronic hemodialysis in our structures during the out-of-center blood pressure measurements campaign. Out-of-center blood pressure measurements could not be done in 21 patients (4 deceased, 2 transplanted and 4 absent before evaluation; 7 arrhythmics; 3 refusals and 1 multiple-disabled). Of these 108 patients (sex ratio 1.25; 69.3±13.5 years), 23 were ineligible for self-blood pressure measurement (visually impaired, neuro- and/or psychological disorders, language barrier). Due to 4 self-blood pressure measurement failures, the feasibility of the self-blood pressure measurement (n=81/129) is 62.8 % (CI95% 54.2-70.7). Of the 24 ambulatory blood pressure measurements performed (23 among those not eligible for self-blood pressure measurement and 1 failure of self-blood pressure measurement), 19 were valid. The "a posteriori" feasibility of out-of-center blood pressure measurements (n=100/129) is 77.5 % (CI95% 69.6-83.4). The feasibility of out-of-center blood pressure measurements in hemodialysis patients is good, making the application of the recommendations possible.

Renal Outcome and New-Onset Renal and Extrarenal Dissections in Patients With Nontrauma Renal Artery Dissection Associated With Renal Infarction.

[Figure: see text].

[Results from recent therapeutic trials in hypertension]. / Qu'ont apporté les essais thérapeutiques récents réalisés dans le domaine de l'hypertension artérielle?

The decrease in systolic/diastolic blood pressure of 100/50 mmHg obtained by antihypertensive therapy is associated with a 22% reduction of coronary events and 41% of cerebrovascular events. The benefit is independent of initial blood pressure level without threshold effect. The benefit is linked to lower blood pressure itself. The doctrine of comparable effectiveness of all antihypertensive drugs is challenged by more recent works. Although patients at high cardiovascular risk in clinical trials included are treated better than before, receiving as many other preventive treatments (statins, aspirin), it seems to remain a high residual cardiovascular risk that seems incompressible.

[The role of patients in the management of hypertension: let's be pragmatic]. / Place des patients dans le contrôle de leur hypertension artérielle: encourager l'autosurveillance.

The management of hypertension and cardiovascular risk factors, which concerns more than 25 percent of the population, is a challenge in an increasingly sedentary world and today's context of a rising prevalence in obesity. The care-focused paternalistic relationship between physicians and patients should evolve for the new generation of physicians, as well as for patients. The last medical resistance to self-measurement of blood pressure should disappear, and it is necessary to meet the rising expectations of patients in terms of information. The failure of lifestyle-related risk factor control, including in secondary prevention, should be investigated. The solution may not lie in an increased role for conventional care systems, as generally suggested by healthcare professionals, who cannot ignore the decrease in medical personnel and the financial pressure placed on all care systems in the world.

Home blood pressure monitoring and e-Health: investigation of patients' experience with the Hy-Result system.

BACKGROUND: Hy-Result is a validated system designed to help patients complying with the home blood pressure monitoring (HBPM) protocol and understanding their blood pressure (BP) readings. It is available as a standalone web application or within a wireless BP monitor app. OBJECTIVE: The aim of the study was to explore patients' experience with Hy-Result. METHODS: Online survey completed by 512 users of the Hy-Result web application or monitor app, and three focus groups with 24 hypertensive patients who monitor their BP at home and use the Hy-Result web application to record their data. We assessed the experience of patients with the functionalities and medical content of Hy-Result, their feelings and expectations, and the impact of Hy-Result on the physician-patient relationship. RESULTS: (1) Functionalities: Over 90% of survey respondents and all focus group participants found Hy-Result easy to use. The main drawback of the web application is the need to manually enter all BP values at once. (2) Medical content: Hy-Result offers information on arterial hypertension and HBPM that most patients found useful. Users found that Hy-Result triggers appropriate reactions to BP readings, including adequately timed general practitioner visits. (3) Feelings and expectations: Over 90% of survey respondents trust Hy-Result and focus group participants understood that text messages are suggestions, not diagnoses. Hy-Result did not cause anxiety or excessive BP measurements. (4) Physician-patient relationship: Three-quarter of survey respondents agreed that Hy-Result may help when talking with their doctor about their BP values but only one-third of those have shown the report to their physician. For focus group participants, using Hy-Result should ideally be a physician prescription. They were aware that Hy-Result does not replace clinical judgment and that physicians still have a decisive role in BP management. CONCLUSION: Most of the users described Hy-Result as an easy-to-use and useful tool. Patients are willing to use it on physician request.

Sequential nephron blockade with combined diuretics improves diastolic function in patients with resistant hypertension.

AIMS: Hypertension is a major contributor to cardiac diastolic dysfunction. Different therapeutics strategies have been proposed to control blood pressure (BP), but their independent impact on cardiac function remains undetermined. In patients with resistant hypertension, we compared the changes in cardiac parameters between two strategies based on sequential nephron blockade (NBD) with a combination of diuretics or sequential renin-angiotensin system blockade (RASB). METHODS AND RESULTS: After a 4-week period where all patients received Irbesartan 300 mg/day + hydrochlorothiazide 12.5 mg/day + amlodipine 5 mg/day, 140 resistant hypertension patients (54.8 ± 11.1 years, 76% men, mean duration with hypertension: 13.1 ± 10.5 years, no previous history of heart failure or current symptoms of congestive heart failure) were randomized 1:1 to the NBD regimen or to the RASB regimen at week 0 (W0, baseline). Treatment intensity was increased at week 4, 8, or 10 if home BP was ≥135/85 mmHg, by sequentially adding 25 mg spironolactone, 20-40 mg furosemide, and 5 mg amiloride (NBD group) or 5-10 mg ramipril and 5-10 mg bisoprolol (RASB group). No other antihypertensive drug was allowed during the study. BP, BNP levels, and echocardiographic parameters were assessed at weeks 0 and 12. The baseline characteristics, laboratory parameters, and plasma hormones (BNP, renin, and aldosterone) and cardiac echocardiographic parameters did not significantly differ between the NBD and the RASB groups. Over 12 weeks, BNP levels significantly decreased in NBD but increased in RASB (mean [CI 95%] change in log-transformed BNP levels: -43% [-67%; -23%] vs. +55% [46%; 62%] in NBD vs. RASB, respectively, P < 0.0001). Similarly, the proportion of patients presenting ≥2 echocardiographic criteria of diastolic dysfunction decreased between baseline and W12 from 31% to 3% in NBD but increased from 19% to 32% in RASB (P = 0.0048). As compared with RASB, NBD induced greater decrease in ambulatory systolic BP (P < 0.0001), pulse pressure (P < 0.0001), and systemic vascular resistance (P < 0.005). In multivariable linear regression analyses, NBD treatment was significantly associated with decreased BNP levels (adjusted ß: -46.41 ± 6.99, P < 0.0001) independent of age, gender, renal function, and changes in BPs or heart rate. CONCLUSIONS: In patients with resistant hypertension, nephron blockade with a combination of diuretics significantly improves cardiac markers of diastolic dysfunction independently of BP lowering.

[Patient reporting of self-measurement results: survey Autoprov]. / Automesure de la pression artérielle: quelle restitution par les patients? Enquête Autoprov.

Nowadays, the benefits and indications of blood pressure self-measurement are well-established and codified by clinical practice recommendations. However, in routine practice, one aspect is still unclear: the way patients report to their physician the results of the measurements taken at home. Few data are available in scientific publications in this respect and the recommended protocols are not adhered to in practice. In a practice survey, 4538 patients instructed to perform blood pressure self-measurement by their general practitioner were asked to report the results on a preprinted sheet and offered the possibility to use the website automesure.com to calculate their average and report the results to their physician. Most patients (81%) were able to provide on a preprinted sheet the results of six measurements per day (three in the morning and three in the evening) on a three-day period (18 measurements in total), and 40% followed the recommendation to use Internet to calculate the average. However, only 12% of patients approximately, significantly younger, were able to use a dedicated application program. As for physicians, they were not ready overall to provide their email address to establish an interactive relationship with their patients.

Nephrotoxicity of iodinated contrast media: From pathophysiology to prevention strategies.

Iodinated contrast media (ICM) induced acute kidney injury (AKI) accounts for 11% of cases of AKI and is its third most common cause in hospitalized patients. However, the pathophysiological mechanisms are not yet completely understood. The nephrotoxicity of ICM is partly the consequence of a direct cytotoxic effect on renal tubular epithelial and endothelial cells. It is also the consequence of impaired intrarenal hemodynamics, these two mechanisms being closely linked. The rheological properties of ICM, the volume infused, and the route of administration increase the intrinsic toxicity generated by the contrast media used. Furthermore, various clinical situations increase the risk of developing AKI. There is no specific treatment. Hydration is the cornerstone of prevention. Preventive measures have reduced the incidence of AKI over the last ten years. After an overview of the pathophysiology of the renal toxicity of ICM, we review risk factors and scores, diagnosis, and means of prevention in the light of the 2018 European Society of Urogenital Radiology and the 2018 American College of Radiology guidelines and recent studies on the subject. In addition, a side-by-side comparison of the updated and less conservative guidelines from the Radiology community and the more cautionary attitude from the Nephrology community are also presented.

Resistant Hypertension and Atherosclerotic Renal Artery Stenosis: Effects of Angioplasty on Ambulatory Blood Pressure. A Retrospective Uncontrolled Single-Center Study.

The effect of renal artery angioplasty on blood pressure in patients with true resistant hypertension and atherosclerotic renal artery stenosis has not been fully investigated due to the exclusion of these patients from most trials. In this study, we assessed the benefits of renal angioplasty on daytime ambulatory blood pressure (dABP) in this subgroup of patients. Medical records of our hypertension department were retrospectively analyzed from 2000 to 2016. Seventy-two patients were identified with resistant hypertension (dABP >135 or 85 mm Hg despite at least 3 antihypertensive drugs, including a diuretic) and atherosclerotic renal artery stenosis treated by angioplasty. Atherosclerotic renal artery stenosis was unilateral in 57 patients and bilateral in 15 patients. The mean age of the patients was 67.8±11.2 years; dABP was 157±16/82±10 mm Hg despite 4.0±1.0 antihypertensive treatments; estimated glomerular filtration rate was 52 (41-63) mL/min. After renal angioplasty, dABPM decreased by 14.0±17.3/6.4±8.7 mm Hg (P<0.001 for both), and the number of antihypertensive treatments decreased to 3.6±1.4 (P=0.002) with no significant change in estimated glomerular filtration rate. A high baseline systolic dABP and a low body mass index were independent predictors of systolic dABP changes. The decrease in dABP was confirmed in a subgroup of patients at one and 3 years of follow-up (N=31 and N=18 respectively, P≤0.001 for systolic and diastolic blood pressure at both visits). In this retrospective uncontrolled single-center study, angioplasty in patients with atherosclerotic renal artery stenosis and with true resistant hypertension significantly decreased dABP, reducing the need for antihypertensive treatment with no change in estimated glomerular filtration rate.