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Renovascular Hypertension

Renovascular Hypertension. Staci Smith DO. Case Presentation. CC: dizziness

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Renovascular Hypertension

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  1. Renovascular Hypertension Staci Smith DO

  2. Case Presentation • CC: dizziness • HPI:62 yo WM presented to GVH w/ complaints of SOB and dizziness for the past three days. Dizziness occurs w/standing up. No LOC, numbness, or tingling. Positive for history of CVA with right sided upper extremity weakness. Pt’s wife has noticed that bp has been fluctuating.

  3. Case Presentation

  4. PMHx: HTN x 20yrs CKD 4-5 CVA PVD AAA CAD L Subclavian stenosis DMT2 (IR) L DVT PSHx: GFF Heart cath CABG x 4v IVC filter Cervical diskectomy EGD / colonoscopy Case Presentation

  5. Aggrenox 200/25 mg two b.i.d Allopurinol 100 mg b.i.d Carvedilol 12.5 mg b.i.d Clonidine 0.2 mg t.i.d Ferrous sulfate 325 mg daily Finasteride 5 mg daily hs Flomax 0.4 mg daily hs Furosemide 80 mg daily Glyburide 5 mg b.i.d Hydralazine 25 mg two tablets t.i.d Isosorbide 60 mg daily Levemir at bedtime Nexium 40 mg daily Plavix 75 mg daily Simvastatin 20 mg q.h.s Medications

  6. Secondary Causes of HTN • Renal Artery Stenosis • Obstructive Sleep Apnea / Obesity • Pheochromocytoma • Thyroid Disease • Cushing’s Syndrome • Hyperaldosteronism • Primary hyperparathyroidism • Congenital Adrenal Hyperplasia • Birth Control • Drugs of Abuse • Caffeine and Diet

  7. Clues to Secondary Causes of Hypertension • Severe or refractory hypertension • Acute rise in blood pressure over a previously stable value • Proven age of onset before puberty • Age less than 30 years • non-obese, non-black patients with a confirmed negative family history of hypertension

  8. When to Suspect Renal Artery Stenosis • Hypertension before the age of 30 years • negative family history and no other risk factors • Onset of severe or stage II hypertension after age 55 yo • Refractory or resistant hypertension • three agents including a diuretic • Acute rise in blood pressure over a previously stable baseline in patients

  9. When to Suspect Renal Artery Stenosis • Unexpected rise in Cr after starting ACE/ ARB • Atrophic kidney size • Flash pulmonary edema or unexplained heart failure • An abdominal bruit that lateralizes to one side

  10. Causes of Renal Artery Stenosis • Atherosclerosis • Fibromuscular dysplasia • Cholesterol embolic disease • Acute arterial thrombosis or embolism • Aortic dissection • Renal arterial trauma or aneurysm • Arteriovenous malformation of the renal artery • Vasculitides

  11. Fibromuscular Dysplasia Vs. Atherosclerosis

  12. Pathophysiology • clinical consequence of renin-angiotensin-aldosterone activation • occlusion of the renal artery causes ischemia • renin release elevates bp • increased renin levels help in the conversion of angiotensin I to angiotensin II • causing severe vasoconstriction and aldosterone release • presence of a functioning contralateral kidney • determines ultimate cascade of events

  13. Pathophysiology

  14. Pathophysiology • Two kidneys are out of sync: • ischemic stenotic kidney produces excessive renin and retains sodium • the comparatively normal kidney continues to excrete sodium and water to maintain normal volume levels • End result is systemic hypertension that is renin and angiotensin mediated

  15. Screening and Diagnostic Testing • Gold standard-renal angiography • Magnetic resonance angiography • Computed tomographic angiography • Duplex Doppler ultrasonography

  16. Screening and Diagnostic Testing • MR Angiography: • increasingly used as the first-line screening test • gadolinium during MR imaging • nephrogenic systemic fibrosis • estimated glomerular filtration rate less than 30 mL/min, avoid gadolinium

  17. MRA of Aorta and Renal Arteries • Gadolinium enhanced MRA • Bilateral RAS

  18. Unilateral Renal Artery Stenosis

  19. Fibromuscular Dysplasia • Beads on a string • Females > Males

  20. Fibromuscular Dysplasia

  21. If GFR less than 30 • risk of radiocontrast nephropathy • Bicarbonate infusion • Mucomyst • IVF • either spiral CT or arteriography can be performed • preferably digital subtraction arteriography with iodinated contrast

  22. Clinical Significance • arteriographic finding of greater than a 75 percent stenosis • in one or both renal arteries • or a 50 percent stenosis with poststenotic dilatation

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