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Background: Malignant hypertension is macrovascular and microvascular endothelial injury responsible for multiple organ damage. Considering the anatomical and functional homologies between the posterior pole of the eye and the kidney, ophthalmological explorations may inform clinicians on the mechanisms underpinning concurrent kidney injury in this condition. More specifically, we investigated whether the wall-to-lumen ratio (WLR) of retinal arterioles measured by adaptive optics ophthalmoscopy could be correlated to WLR of kidney arterioles as determined by pathology. We sought to estimate the incidence of retinal arteriole occlusion a supposedly uncommon complication of malignant hypertension., Methods: All patients hospitalized in our renal Intensive Care Unit for malignant hypertension between 2016 and 2019 were referred to ophthalmological examinations., Results: Twenty-seven patients were included. Median retinal WLR was 0.39 [0.31-0.47] and was correlated with initial systolic (r = 0.56, P = 0.003) and mean blood pressure (r = 0.46, P = 0.02) upon admission. The retinal WLR was not correlated to renal pathological findings, as assessed by juxtaglomerular WLR (r = 0.38, P = 0.2), ratio of glomerulosclerosis (r = -0.39, P = 0.2), or tubulointerstitial fibrosis (r = -0.45, P = 0.08). Retinal WLR was not associated with neurological or cardiovascular end-organ damage. Branch retinal artery occlusion was detected in 18.5% of patients and exudative retinal detachment (ERD) in 29.6% of patients, without any significant correlation with canonical signs of retinal hypertension including optic disc swelling., Conclusions: In the setting of malignant hypertension, we failed to demonstrate a significant relationship between WLR and other meaningful end-organ injuries. However, branch retinal artery occlusion and ERD may have been hitherto underestimated., (© American Journal of Hypertension, Ltd 2020. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

The classification and management of hypertensive crisis have been recently reviewed in the context of both European and American guidelines. The key points for proper blood pressure control in severe arterial hypertension are: 1 - Distinction between urgent intervention and emergencies 2 - Choice of the best drug(s) 3 - Choice of the correct route of administration. In patients with renal disease, beside the common causes of hypertension/ hypertensive crises, kidney-specific causes should be taken into account such as renal parenchymal hypertension, renovascular hypertension, sclerodermic crises, and preeclampsia.

In this clinico-pathologic study, post-mortem kidney material from 30 cases with malignant hypertension (MHT) defined as severe hypertension with bilateral retinal haemorrhages and exudates (grade III retinopathy) with (grade IV retinopathy) or without papilloedema, were studied. Mucoid intimal proliferation (MIP) in interlobular artery and ischaemic collapse of the glomerular tufts occurred in all cases, whereas fibrinoid necrosis (FN) was seen in only 24 (80%) of the cases. FN was not correlated nor associated with sex, age, blood pressure, retinopathy or serum creatinine. Tubular atrophy and interstitial fibrosis occurred in 24 (80%) and correlated best (rS = 0.8, p < 0.05) with serum creatinine in comparison to glomerular sclerosis (rS = 0.6, p = n.s), fibrinoid necrosis (rS = 0.49, p = n.s) and epithelial crescents (rS = 0.43, p = n.s). This study provides histologic evidence of lack of difference between grades III and IV retinopathy, shows MIP as the more characteristic vascular lesion in MHT and also, good correlation between renal function and tubulointerstitial involvement.

The occurrence of renal scleroderma (RSc) was sought retrospectively in 36 consecutive patients with scleroderma, seen in a single rheumatology unit, over a 12-year period. The diagnosis RSc was considered when at least one of the following findings was present: systolic blood pressure greater than or equal to 95 mmH, proteinuria greater than or equal to 0.5 gr/24 hr., and creatinine clearance less than or equal to 50 ml/min.: at least one of these features was found in 16 patients. Hypertension was the most frequent feature of RSc (15 out of 16 patients). Two forms of hypertension were observed. Firstly: malignant hypertension occurring early in the course of RSc, seen in 5 patients, 4 of whom rapidly developed terminal renal insufficiency. Secondly: a moderate hypertension, seen in 10 patients with a more favourable outcome, occurring on average 53 months after the diagnosis of scleroderma was made. Proteinuria was only seen in association with malignant hypertension. Renal impairment occurred in 7 patients. Of the 36 patients with scleroderma, 14 died; 10 of these 14 patients had RSc. Thus the death rate in patients with RSc was very high, whereas only 4 out of 20 died in the group without RSc.