Which one of the following is of most serious prognostic significance in a patient of essential hypeension-

In more than 95% of cases, a specific underlying cause of hypeension cannot be found. Such patients are said to have essential hypeension. The pathogenesis of this is not clearly understood. Many factors may contribute to its development, including renal dysfunction, resistance vessel tone, endothelial dysfunction, autonomic tone, insulin resistance and neurohumoral factors.~80-95% of hypeensive patients are diagnosed as having "essential" hypeension (also referred to as primary or idiopathic hypeension).Essential hypeension tends to be familial and is likely to be the consequence of an interaction between environmental and genetic factors. The prevalence of essential hypeension increases with age, and individuals with relatively high blood pressures at younger ages are at increased risk for the subsequent development of hypeension. It is likely that essential hypeension represents a spectrum disorders with different underlying pathophysiologies. In the majority of patients with established hypeension, peripheral resistance is increased and cardiac output is normal or decreased; however, in younger patients with mild or labile hypeension, cardiac output may be increased and peripheral resistance may be normal. When plasma renin activity (PRA) is plotted against 24-h sodium excretion, ~10-15% of hypeensive patients have high PRA .Inconsistent associations between plasma aldosterone and blood pressure have been described in patients with essential hypeension.papilledema with renal failure is the most serious prognostic feature of essential hypeension. ref:Harrison&;s principles of internal medicine,ed 18,pg no 2450