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  • The Internet Journal of Internal Medicine
  • Volume 6
  • Number 1

Original Article

Hypertension Associated To Urolithiasis

S Ortega, J Vizcaino

Keywords

allopurinol, hypertension, thiazides, urolithiasis

Citation

S Ortega, J Vizcaino. Hypertension Associated To Urolithiasis. The Internet Journal of Internal Medicine. 2005 Volume 6 Number 1.

Abstract

In a group of 900 hypertensive patients we analyze the prevalence and the treatment response in the sub-group with urolithiasis. The prevalence of urolithiasis was 13,7%, and the prevalence of urolithiasis by hypercalciuria and/or hyperuricosuria was 12.3%. The control level to the treatment in the last sub-group with thiazides and/or allopurinol was 59,5%. The hypertensive patients with this type of urolithiasis and without hypertension control with this treatment were the intolerant patients to thiazides and/or allopurinol (6,3%) and the obese hypertensive patients (34,2%). These data help to explain why the thiazide diuretics have been the antihypertensive drugs that have given better results in the ALLHAT study and they still are continuing in the current recommendations like first line antihypertensive drugs

 

Background

Observacionals studies suggest the hypertension and urolithiasis association could be related in his etiology, pathogenesis and treatment1,2,3,4,5. It would determine that we simultaneously treated the hypertension, the urolithiasis, and the potential osteoporosis and dental alterations6,7 using thiazide diuretics and allopurinol. These problems (urolithiasis, osteporosis and dental alterations) undergo with high prevalence and in a combined way in the hypertensive patients.

We reviewed the association of hypertension and urolithiasis in an office, and we suggest could give the basis for explain the results of ALLHAT study8,9,10.

Patients and Methods

In an hypertension office we analyze the sub-group of hypertensive patients with urolithiasis associated to hypercalciuria and/or hyperuricosuria. Hypertension was defined as a blood pressure of at least 140/90 mm Hg or inferior if antihypertensive medication was used.

This study corresponds to health area with a population of 425000 inhabitants. Of 900 hypertensive patients 124 (13,7%) have presented urolithiasis on the basis of hystory and/or abdominal ultrasonic study. Of 124 hypertensive patients with urolithiasis, 111(12,3%) presented hypercalciuria and/or hyperuricosuria. A general protocol was practiced at this 124 hypertensive patients with urolithiasis, which it included SMA (twice) of 22 determinations, urinary sediment and in the urine of 24 hours creatinin, calcium, uric acid, oxalate and citrate. Hyperparathyroidism was discarded with levels of calcemia, phosphorus and parathyroid hormone. At a sub-group of 111 hypertensive patients without urolithiasis was practiced the same protocol and was considered control of the sub-group with urolithiasis with hypercalciuria and/or hyperuricosuria. We valued the prevalence and the response to the treatment with the association thiazides and/or allopurinol to the sub-group of hypertensive patients associated to urolithiasis with hypercalciuria and/or hyperuricosuria. The data was analized with informatic program RSIGMA.

Results

Of the 124 hypertensive patients with urolithiasis 111 presented hypercalciuria and/or hyperuricosuria, 3 with hypocitraturia and the rest other alterations. The average age of the urolithiasis with hypercalciuria and/or hyperuricosuria was of 46.2±11.2 years. Of them 61 (55%) was men. In the sub-group with hypercalciuria and/or hyperuricosuria the daily average elimination of calciuria was of 338±3 mg (normal < 260 mg per 24 hours), being in the interval 803-269 mg. The average elimination of uric acid in urine of 24 hours was of 763±9 mg (normal <10 mg/kg/per day), being included in the interval of 248-1465 mg. The calciuria (226±2) and the uricosuria (563±6) in the sub-group of 111 hypertensive patients without urolithiasis were inferior to the sub-group with urolithiasis (p<0,05).

Seven (6,3%) cases affected of hypercalciuria and/or hyperuricosuria did not tolerate the association thiazides-allopurinol. On the rest (104 hypertensive patients), in 102 patients was controlled the hypercalciuria and/or hyperuricosuria with thiazides and/or allopurinol and in 66 (59,5%) the hypertension was controlled with this association. Two patients which persisted with hypercalciuria and/or hyperuricosuria continued with clinical of urolithiasis. The 38 (34,2%) patients without control of hypertension were obese with body mass index superior to 30 kg/m2.

A familiar history was detected in 48 (43,2%) hipertensive patients with urolithiasis hypercalciuria and/or hyperuricosuria.

Discussion

With this data we think that the hypertension-urolithiasis association would be considered in the initial evaluation of hypertensive patients3,4,5. On this way we value make to all hipertensive patients an abdominal ultrasonic study, since the most of secondary causes of hypertension are at level of suprarrenal glands or in the urinary system; it´s including the urolithiasis. We are reviewing these results of sequential way, in the hypertension office, and we are watching the elevated prevalence of urolithiasis-hypertension association persists superior to 12% along the study11. We can assume that this´s one explanation to thiazide diuretics are very useful in the treatment of hypertension. It would be important comment that the loop diuretics, increasing calciuria, probably would lose the therapeutic effects of thiazide (Table I). On this way the loop diuretics would not be in the antihypertensive initial treatment, unless cardiac or renal insufficiency exists.

Figure 1
Table 1

Recently a paper has been published12 contradicting to the study ALLHAT, and that it´s showing the contradictions in which the medical Literature is immersed.

As a summary we can conclude: 1. - The hypertension associated to urolithiasis could be considered like specific form of secondary hypertension, in probably relation to tubular kidney anomalies13, cause of hypercalciuria and/or hyperuricosuria; 2.- In the presence of hypertension associated to hypercalciuria and/or hyperuricosuria urolithiasis the combination of thiazides and/or allopurinol controls both alterations (hypertension and urolithiasis) in the most of the cases; 3. - The hypertensive patients with urolithiasis which require other associations of antihypertensive drugs to the thiazides for the hypertension control probably have other etiologies associated to this metabolic anomaly, like obesity 4.- The familiar association of hypertension-urolithiasis represents one more reason in hereditary basis of the hypertension.

Correspondence to

Saturnino Suarez Ortega Urbanización El Arco 16. La Atalaya. 35307 Santa Brigida Las Palmas. Spain. Tf (34-28)928430263 E.mail: drsuarez@hotmail.com

References

1. Burt WL, Whelton P, Rocella EJ et al. Prevalence of hypertension in the adult US population. Results from the third National Health and Nutrition Examination survey 1988-1991. Hypertension 1995; 25: 305-13.
2. Strazzullo P, Cappuccio FP. Hypertension and kidney stones: hypothesis and implications. Semin-Nephrol 1995; 15: 519-525.
3. Strazzullo P, Mancini M. Hypertension calcium metabolism and nephrolithiasis. Am J Med Sci 1994; 307 Spp l1: S102-6.
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5. Strazzullo P, Barba G, Vuottto P, Farinaro E, Siani A, Nunziata V, Galletti F, Manzini M, Cappucio FC. Past history of nephrolithiasis and incidence of hipertensión in men: a reapraisal based on the results of the Olivetti Prospective Heart Study. Nephron Dial Transplant 2001; 16: 2232-35.
6. Johansson I, Tidehag P, Lundberg V, Hallamans G. Dental status, diet and cardiovascular risk factors in middle-aged people in northern Sweden. Community Dent Oral Epidemiol 1994; 22: 431-36.
7. Reid IR, Ames RW, Orr-Walker BJ et al. Hydrochlorothiazide Reduces loss of Cortical Bone in Normal Postmenopausal Women: A Randomized Controlled Trial. Am J Med 2000; 109: 362-70.
8. The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting-enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002: 288: 2981-97.
9. Appel LJ. The verdict from ALLHAT. Thiazide diuretics are the preferred initial therapy for hypertension. JAMA 2002; 288: 3039-42.
10. Davis BR, Piller LB, Cutler JA, et al for the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Role of diuretics in the prevention of heart failure: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Circulation 2006; 113: 2201-10.
11. Morales F, Suarez S, Artiles J, Blesa R, Aguilar P, De la Calle M. Litiasis urinaria hipercalciurica-hiperuricosurica e hipertension arterial. Congreso Internacional de Medicina Familiar y Comunitaria. Granada. Spain. Noviembre 1996.
12. Wing LMH, Reid CM, Ryan P et al. A comparison of Outcomes with Angiotensin-Converting-Enzyme Inhibitors and diuretics for Hypertension in the Elderly. N Eng J Med 2003; 348: 583-92.
13. Zoccali C, Mallamaci F, Curatola G, et al. Mechanism of hypercalciuria in essential hypertension and primary nephrolitiasis. Contrib Nephrol 1991; 90: 49-53.

Author Information

Saturnino Suarez Ortega, M.D.
Internal Medicine, Hospital General de Gran Canaria Dr. Negrin

Jeronimo Artiles Vizcaino, M.P.
Internal Medicine, Hospital General de Gran Canaria Dr. Negrin

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