Treatment of malignant hypertension with infusion of sodium chloride; A case report and a review.

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Abstract
A man, now 46 yr old, 159 cm in height and 39 kg in weight, was diagnosed 5 yr ago as essential hypertension with hypertensive nephropathy. On that occasion, renovascular stenosis was ruled out angiographically. He developed malignant hypertension and was admitted to our hospital. On admission, severe hypertension (260/160 mmHg), hyponatremia (132 meq/l), high reninemia (40.0 ng/ml; normal, 5.0-30.0 ng/ml), high serum aldosterone level (840 pg/ml; normal, 10-100 pg/ml) and advanced retinal changes (KW-III [Keith-Wegener class III]) were found. He lost 10 kg in weight during the preceding 3 mo. Other characteristic laboratory findings were hypopotassemia (3.8 meq/l), hypochloremia (85 meq/l), slight alkalosis, high serum lactate dehydrogenase level, increased cardio-thoracic ratio and milk azotmia (BUN[blood urea nitrogen]-46 mg/100 ml, serum creatinine-3.8 mg/100 ml). As a therapeutic trial, .beta.-blocker and hydralazine were administered but no improvement was obtained. Then, Na was infused in a dose of 328 meq dissolved in 1500 ml water in a time period of 12 h. After the start of Na supplementation (1 h), his blood pressure was dramatically decreased to 174/120 mmHg; 3 h after the infusion, the blood pressure was 149/90 mmHg; 1 h after the end of the infusion, the blood pressure remained as low as 130/90 mmHg. At the end of the infusion serum Na rose to 141 meq/l, PRA [plasma renin activity] decreased to 8.0 ng/ml, serum aldosterone level fell to 250 pg/ml, urinary Na excretion decreased and body weight increased by 1.5 kg. In this patient, extreme hypertension caused an excessive diuresis causing fluid and Na depletion in the body, which, in turn, increased renin release and blood pressure elevation. Malignant hypertension with hyponatremia and emaciation is an indication of parenteral Na supplementation and most important in the control of malignant hypertension is to keep the Na balance in an appropriate range.

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