Pathology of Hypertension:

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If one advances confidently in the direction of
his dreams, he will meet with a success
unexpected in common hours --Henry David Thoreau
"Shoot for the moon.  Even if you miss it, you
will land among the stars.!" - Les Brown 
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Pathology of Hypertension

• Dr. Venkatesh M. Shashidhar.
• Associate Professor of Pathology
• Fiji School of Medicine

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Hypertension - Introduction

• Silent Killer painless complications
• dizziness, headache, and visual difficulties,
• It is the leading risk factor MI, DM, Stroke
• 25 of population, lt35 unaware. lt5 ..!

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Introduction

• Complications bring to diagnosis but late
• Sustained increase in blood pressure
• Systolic gt140, Diastolic gt 90 mm of Hg

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Control of Blood Pressure
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Etiologic Classification

• Primary or Essential Hypertension(95)
• Secondary Hypertension (5-10)
• Renal Kidney disorders.
• Other endocrine, drugs etc.

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Pathogenesis of complicationsOf Hypertension
Ishchemia MI, CNS, Kidney, eye Aneurism /
Rupture CNS, Aorta, Myocardial
Hypertrophy LVH, Cardiac failure.
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Consequences of Hypertension

• Blood Vessels
• Atherosclerosis, Arteriolosclerosis.
• Heart
• Enlarge, Ischemia, Infarction.
• Kidney
• Ischemia, Infarction - nephrosclerosis.
• Eyes
• Retinopathy Ischemia, infarction.
• Brain
• Ischemia, infarction, Haemorrhages.

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Thickening of blood vessel
Narrow Lumen
Onion Skin Thickening Of arterioles.
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Hypertrophy of heart
Left Ventricular Hypertrophy
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Brain Haemorrhage

• Cerebral Blood vessels
• Special features
• Thin walled
• End arteries
• Cong. Aneurisms

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Cerebral Infarction (Stroke)
Haemorrhagic Necrosis
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Cerebral Infarction
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Kidney damage Benign Nephrosclerosis
Leathery Granularity due to minute scarring
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Risk Factors for Atherosclerosis

• Hypertension Hyperplastic A. sclerosis
• Diabetes Hyaline A. sclerosis
• Smoking Endothelial damage.
• Hypercholesterol Endothelial damamge
• Life style, lack of exercise, stress, obesity.
• All factors damaging Blood vessels predispose to
  development of atherosclerosis.

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Normal Retina - Fundoscopy
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Hypertensive Retinopathy
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Conclusions

• Persistent increased blood pressure (140/90)
• 95 Essential, 5 secondary - Renovascular
• Benign and Malignant types (gt120Diastolic)
• Vessel damage Arteriolosclerosis
• Complicates - Atherosclerosis, Diabetes, IHD
• Ischemia or Infarction in end organs.
• Kidney, Brain, Heart Eyes.
• Nephrosclerosis, renal damage, IHD, MI, Stroke
  Retinopathy.

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Pathology of Diabetes

• Dr. Venkatesh M. Shashidhar
• Senior Lecturer in Pathology
• Fiji School of Medicine

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Diabetes Mellitus

• Disorder of metabolism (Carb, Prot Fat)
• Due to Absolute or relative deficiency of
  insulin.
• Characterized by hyperglycemia.
• Clinically Polyuria, Polydypsia, Polyphagia.

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Classification

• Primary DM.
• Type I IDDM / Juvenile 10.
• Type II NIDDM /Adult onset 80.
• MODY 5 maturity onset - young - Genetic
• Secondary DM islet destruction.
• Infectious congenital rubella, CMV.
• Pancreatitis/tumors/Hemochromatosis.
• Endocrinopathy, gestational DM, downs.
• Drugs Corticosteroids.

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Pathogenesis of Type I DM
Environment ? Viral infe..??
Genetic HLA-DR3/DR4
Autoimmune Insulitis
ß cell Destruction
Severe Insulin deficiency
Type I DM
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Pathogenesis of Type II DM
Environment Obesity ???
ß cell defect Genetic
Insulin resistance
Abnormal Secretion
Relative Insulin Def.
ß cell exhaustion
IDDM
Type II DM
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Complications

• Short term Complications (metabolic)
• Hypoglycemia
• Diabetic Ketoacidosis
• Non Ketotic hyperosmolar diabetic coma
• Lactic acidosis
• Long term Complications(microangiopathy)
• Angiopathy, Retinopathy, Nephropathy, Neurophathy

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Long term Complications

• Angiopathy
• Atherosclerosis
• Hyaline arteriolosclerosis
• Diabetic microangiopathy
• Nephropathy
• Nodular glomerulosclerosis
• Retinopathy
• Non Proliferative Proliferative
• Neuropathy
• Peripheral axonal neuropathy

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Pathogenesis of Microangiopathy

• Long standing diabetes
• Glycosylation of BV proteins.
• Protein deposits in the BM.
• Thick and Leaky blood vessels
• Exudation Ischemia
• End Organ damage...

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Diabetic Micro-angiopathy is the primary cause
of diabetic pathies (hyaline
arteriolosclerosis)
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Infections in Diabetes

• Blood vessel damage ischemia
• Decreased intracellular glucose - ?defence
• Glycosylation of inflammatory mediators
• Glycosylation of immunoglobulins
• Lastly increased glucose in blood.
• Not just due to increased glucose.!

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Microangiopathy
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Pathogenesis of Complications
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Atheroma Coronary Artery
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Diabetic Gangrene
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Normal Retina
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Diabetic Retinopathy
Cotton wool spots
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Pathogenesis of Nephropathy
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Diabetic Glomerulosclerosis
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Laboratory Diagnosis

• Urine glucose - dip-stick Screening
• Random or fasting blood glucose (lt11)
• Fasting gt 7mmol, Random gt11mmol
• If Fasting level is between 7-11 then OGTT
• HbA1c - for follow-up, not for diagnosis
• Fructosamine - for long term maintenance.

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Take home points

• Type-I Young, Acute Metabolic complications -
  Ketoacidosis.
• Type-II - Chronic Vascular complications
• Microangiopathy Kidney,Retina,Brain, BV.
• Hypoglycemia is more dangerous.

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Take home points

• Duration level of hyperglycemia are directly
  proportional to Chronic (Vascular) complications.
• Infections are due to microangiopathy and
  ischemia, immuno suppression and lastly
  hyperglycemia.