Renal Dysfunction and Hemodynamics Investigated as Markers of Hypertension with Malignant Signs

In diagnosing severe hypertension with malignant signs, physicians have relied heavily on such clinical criteria as rapid progression of renal disturbance, KW III-IV type ocular fundi, and extremely high diastolic blood pressure (dBP). However, KW III-IV type ocular fundi and extremely high dBP are not necessarily manifested concurrently. In 45 patients of severe hypertension with either KW III or KW IV ocular fundi, we reevaluated the diagnostic criteria in light of renal dysfunction and hemodynamic deviation. The KW III group of 31 patients (21 male, 10 female, 51±10 years old) and the KW IV group of 14 patients (5 male, 9 female, 46±12 years old) were subdivided in three groups according to dBP (≦114 mmHg, 129〜115 mmHg, and ≧130 mmHg), and renal function was determined by the renal clearance test. Wezler's method was used to assess the hemodynamics. The hemodynamic type of hypertension with malignant signs was associated with high cardiac output (CO) in 13 of 31 patients in the KW III group and in 7 of 12 in the KW IV group, whereas high total peripheral resistance (TPR) type is more commonly seen in patients with benign hypertension. Creatinine clearance rate (Ccr) and renal blood flow (RBF) decreased markedly in KW IV group, particularly in patients with high-CO type hypertension. As a result, the RBF-to-CO ratio decreased with aggravation of renal function, and consequently in all cases of KW IV ocular fundi the ratio appeared under normal range (RBF/CO<1/10). A decrease in either Ccr, RBF or RBF/CO ratio had no apparent relationship with dBP elevation. Congestive heart failure (CHF) was observed in all patients of the KW IV group, and high-CO type hypertension was noted in 6 of 8 patients with CHF not clearing, but in only 1 of 6 with CHF clearing. In the KW III group, CHF was observed in 18 of 31 patients with high-CO type hypertension, in 3 of 6 patients with CHF not clearing and in 4 of 12 with CHF clearing. A correlation between CHF and the rise in dBP was evident in them. These results suggest that elevated dBP, is frequently associated with the development of CHF, and CHF in severe hypertension was often characterized by high cardiac output failure in the presence of severe renal dysfunction.