Figure 1 Left. Diffuse calcification of blood vessels of the arm. Right. Diffuse calcification of blood vessels of the leg. These changes were noted bilaterally.

Pseudohypertension Due to Diffuse Vascular Calcification in Chronic Renal Failure LARRY J. JACOBS, M.D.; HOWARD MANTEN, M.D.; ROBERT J. MYERBURG, M.D.; and DAVID S. SHEPS, M.D. University of Miami School of Medicine; Miami, Florida METASTATIC

SOFT-TISSUE

CALCIFICATION

is

a

well-

k n o w n complication of chronic renal failure. W e describe pseudohypertension (that is, cuff systolic blood pressure higher than 3 0 0 m m H g without intravascular hypertension) due to diffuse arterial calcification occurring in a patient with chronic renal failure. A 63-year-old Hispanic man was admitted to the Jackson Memorial Hospital coronary care unit complaining of chest pain. His history was remarkable for chronic renal failure of 4 l / 2 years' duration, for which he required hemodialysis three times weekly. He reported that for the past several months his blood pressure had been "unobtainable" at the dialysis center. Communication with the other hospital confirmed that, even

with an electronic device, a blood pressure reading had not been recorded for 1 year. On admission, the blood pressure in the right arm, could not be auscultated with a stethescope, but exceeded 300 mm Hg by palpation; this was confirmed by a Doppler device. Because the hemodialysis access site was located in the left arm, blood pressure recordings were not initially obtained from this extremity. Measured with the Doppler device, however, blood pressure recorded in the left popliteal artery was 120 mm Hg systolic; no Korotkoff sounds were heard in the right leg. These readings were confirmed by several observers, using various blood pressure cuffs and manometers. Pulse was 80 and irregular. Dense cataracts precluded fundscopic examination. Findings in the remainder of the physical examination were remarkable for jugular venous distension, bibasilar moist rales, and a grade II/VI systolic ejection murmur heard best at the lower left sternal border. There were no abdominal bruits or organomegaly, and examination of the extremities showed chronic venous stasis without edema. Neurologic examination showed diminished perception of vibratory stimuli. Pulses were 2 + / 2 + in the carotid, brachial, and radial arteries, but were not palpable in the arteries of the legs. Pertinent laboratory data included blood urea nitrogen, 104 mg/dl; creatinine, 18 mg/dl; calcium, 8.9 mg/dl; and phosphorus, 5.9 mg/dl. An electrocardiogram showed no acute changes, and a chest roentgenogram showed generalized cardiomegaly with mild pulmonary vascular congestion. Calcification of both the mitral annulus and aortic cusps was observed on echocardiography. There was no evidence of pericardial effusion. The history of prolonged chest pain in the context of very high blood pressure recordings prompted vigorous attempts to obtain more accurate blood pressure measurements. Attempts to catheterize the radial, brachial, femoral, and temporal arteries were unsuccessful, and nitroprusside was begun with palpated right-brachial pressure used as the index of true intravascular pressure. An infusion as high as 70 fxg/min failed, however, to lower the pressure to below 300 mm Hg. When hemodialysis was begun shortly afterward,"a blood pressure of 80 mm Hg was recorded from the access site catheter, with the catheter tip located adjacent to the arteriovenous fistula, while the vein side of the fistula was occluded. During this measurement cuff pressure in the right arm remained higher than 300 mm Hg. It was appreciated then that noncompressibility due to vascular calcification might be likely to account for the spuriously high blood pressure recordings, and roentgenograms of the extremities were obtained. These showed diffuse "pipe-stem" calcification of the arterial tree, involving both upper and lower extremities bilaterally (Figure 1). Pipe-stem brachial arteries have been reported to cause pseudohypertension in a patient with Monckeberg's arteriosclerosis (1). T h i s condition is characterized by calcification o f the tunica media, without apparent cause. In chronic renal failure, however, derangements o f calcium Brief Reports

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and phosphorus metabolism are responsible for soft-tissue calcification. Two types of arterial calcification are recognized radiographically: small dense shadows representing calcification of intimal atheromatous plaques and more diffuse pipe-stem densities representing calcification in the tunica media. The latter resembles "idiopathic" Monckeberg's arteriosclerosis (2). Pipe-stem arterial calcifications associated with renal failure are usually asymptomatic, although gangrenous changes have been reported to occur in association with them (3-5). Hypertension is a well-known complication of chronic renal disease; but we are not aware of pseudohypertension secondary to vascular calcification occurring in patients with chronic renal failure. Because vascular calcification and hypertension are so common in patients with chronic renal failure, it is conceivable that spurious elevations of cuff blood pressure may be more widespread than is currently appreciated. On the basis of our observation in this patient, we are now measuring intravascular pressures in all patients with the triad of renal failure, vascular calcifications, and marked auscultatory hypertension before initiating antihypertensive therapy. This is done partly to avoid the pitfall of treating pseudohypertension with antihypertensives and to ascertain the frequency of this phenomenon. REFERENCES

1. TAGUCHI JT, SUWANGOOL P: "Pipe stem" brachial arteries. A cause of pseudohypertension. JAMA 228:733, 1974 2. PARFITT AM: Soft tissue calcification in uremia. Arch Intern Med 124:544-556, 1969 3. F R I E D M A N SA, N O V A C K S, T H O M S O N GE: Arterial calcification

and

gangrene in uremia. JV Engl J Med 280:1392-1394, 1969 4. R O S E N H, F R I E D M A N SA, R A I Z N E R AE, G E R S T M A N N K: Azotemic ar-

teriopathy. Am Heart J 84:250-255, 1972 5. G I P S T E I N RM, C O B U R N JW, A D A M S DA, L E E DBN, PARSA K P , S E L L ERS A, SUKI WN, MASSRY SG: Calciphylaxis in man. A syndrome of

tissue necrosis and vascular calcification in 11 patients with chronic renal failure. Arch Intern Med 136:1273-1280, 1976 © 1 9 7 9 American College of Physicians

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March 1979 • Annals of Internal Medicine • Volume 90 • Number

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Pseudohypertension due to diffuse vascular calcification in chronic renal failure.

Figure 1 Left. Diffuse calcification of blood vessels of the arm. Right. Diffuse calcification of blood vessels of the leg. These changes were noted b...
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