renal artery stenosis an important cause of hypertension n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Renal Artery Stenosis: An important cause of hypertension PowerPoint Presentation
Download Presentation
Renal Artery Stenosis: An important cause of hypertension

Loading in 2 Seconds...

play fullscreen
1 / 42

Renal Artery Stenosis: An important cause of hypertension - PowerPoint PPT Presentation


  • 158 Views
  • Uploaded on

Renal Artery Stenosis: An important cause of hypertension. Dr Claire Hathorn SpR, RHSC Edinburgh 11 th May 2010. Presentation. 3 year old girl Well Minor intercurrent illness – A&E BP 144/91. History & Examination. Asymptomatic PMH – Eczema, viral induced wheeze FH – nil of note

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Renal Artery Stenosis: An important cause of hypertension' - kera


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
renal artery stenosis an important cause of hypertension

Renal Artery Stenosis: An important cause of hypertension

Dr Claire Hathorn

SpR, RHSC Edinburgh

11th May 2010

presentation
Presentation
  • 3 year old girl
  • Well
  • Minor intercurrent illness – A&E
  • BP 144/91
history examination
History & Examination
  • Asymptomatic
  • PMH – Eczema, viral induced wheeze
  • FH – nil of note
  • Normal examination
  • Height and weight on 97th centile
initial investigations
Initial Investigations
  • BP 120-140 / 90-100 mmHg
  • Urinalysis negative
  • FBC, U&Es, LFTs, coagulation
  • 4 limb BP
  • ECG
  • Renal USS & dopplers
  • ALL NORMAL
further investigations
Further Investigations
  • Renin 2.6
  • Aldosterone 136
  • Cortisol 192
  • PTH 34
  • ACTH 12
  • Complement 560
  • C3 1.01
  • C4 0.18
  • ANA neg
  • Urine catecholamines N
  • Urine cortisol 11.9
  • Urine prot:creat ratio 39

(slightly raised)

  • Urine MC&S negative
radiology
Radiology
  • Echo – normal
  • DMSA – divided function 50%
  • MR Angiogram – slight irregularity of superior surface of right renal artery, felt unlikely to represent stenosis. No evidence of duplex. Conclusion: normal.
specialist opinions
Specialist Opinions
  • Cardiology:
    • No clinical evidence of coarctation
    • No LVH on Echo
  • Ophthalmology
    • Examination normal
    • No hypertensive retinopathy
  • No cause or complication of hypertension
impression management
Impression & Management
  • Blood pressure not well-controlled on 3 drugs
    • Atenolol 20mg bd
    • Amlodipine 2.5mg od
    • Doxazosin 0.5mg od
  • Renovascular disease most likely diagnosis
  • Referred for formal angiography at Great Ormond Street Hospital
angiography
Angiography
  • Critical stenosis of left upper pole branch of main renal artery
  • Normal right renal arteries
  • Angioplasty performed
  • Atenolol & Doxazosin stopped
  • Aspirin started
progress
Progress
  • Remained hypertensive 1 month post-angioplasty: 120/61
  • Amlodipine continued
  • Doxazosin restarted
  • 3 months post-angioplasty,

BP well-controlled: 50-75th centile

renovascular hypertension
Renovascular Hypertension
  • Aetiology
  • Clinical Features
  • Investigations
  • Management
renovascular hypertension1
Renovascular Hypertension
  • 5-10% of all childhood hypertension
  • Amenable to potentially curative treatment
  • Causes & management different to adults
aetiology in children
Aetiology in Children
  • Fibromuscular dysplasia – most common in UK
  • Syndromes: Neurofibromatosis, Williams, Marfan
  • Vasculitides: Takayasu, Kawasaki
  • Extrinsic compression: Wilm’s, Neuroblastoma
  • Other: Renal transplant, trauma, radiation
clinical spectrum
Clinical Spectrum
  • Bilateral disease in 53-78%
  • Intrarenal disease in 44%
  • Intrarenal & main artery stenosis in 31%
  • Most children without co-morbidities have single focal branch artery stenosis

Tullus et al. Renovascular hypertension in children. Lancet. 2008;371:1453-1463

anatomic distribution of renal artery stenosis in children implications for imaging
Anatomic distribution of renal artery stenosis in children: implications for imaging
  • Cinncinnati Children’s Hospital, 1993-2005
  • 24 stenoses identified in 21 children, R=L
  • 12 male, mean age 9yrs 3mths (30 mths – 18 yrs)
  • No co-morbidities
  • 90% children had a single stenosis
  • 75% lesions located in branch / accessory arteries

Vo et al. Pediatric Radiology 2006;36:1032

clinical features
Clinical Features

Schroff et al. Angioplasty for renovascular hypertension in children: 20 year experience. Pediatrics 2006;118:268-275

implications of widespread arterial disease
Implications of widespread arterial disease
  • Improved BP control
    • 11/13 (85%) isolated RAS
    • 6/20 (30%) associated intra or extra renal disease
  • Recommend routine cerebrovascular imaging
    • MR / PET scanning

Schroff et al. Angioplasty for renovascular hypertension in children: 20 year experience. Pediatrics2006;118:268-275

investigation
Investigation
  • Doppler ultrasound
  • Measurement of plasma renin activity
    • Captopril plasma renin test
    • Renal vein sampling
  • Scintigraphy: DMSA or MAG3
  • CT & MR angiography
  • Angiography: Gold Standard
dmsa scintigraphy before after captopril
DMSA scintigraphy before & after Captopril

Tullus et al. Renovascular hypertension in children. Lancet. 2008;371:1453-1463

ct angiogram
CT Angiogram

Tullus et al. Renovascular hypertension in children. Lancet. 2008;371:1453-1463

angiography1
Angiography
  • With carefully selected patients, 40% RAS
  • Important therapeutic opportunity
  • Visualisation of abdominal vessels
angiography indications
Angiography: Indications
  • Tulles et al. (2008)
    • BP >95th centile not well-controlled on 2 drugs
    • Other cause not identified
  • Vo et al. (2006)
    • Unexplained persistent HT > 95th centile
  • Shahdadpuri et al. (2000)
    • BP > 99th centile not controlled with 1 drug
    • Angiography abnormal in 43% patients
a 4 year old hypertensive boy
A 4-year-old hypertensive boy

Vo et al. Anatomic distribution of RAS in children. Pediatric Radiology 2006;36:1032

14 yr old hypertensive girl
14 yr old hypertensive girl

Vo et al. Anatomic distribution of RAS in children. Pediatric Radiology 2006;36:1032

medical management
Medical Management
  • Anti-hypertensives
    • Multiple often required
    • Adequate BP control often not possible
    • Adverse effects common
    • Avoid ACE inhibitors & angiotensin receptor blockers
  • Concern re renal function if BP well-controlled due to under-perfusion of kidneys
angioplasty
Angioplasty
  • 1980 : 1st successful angioplasty in a child
  • Balloon diameter equal to proximal artery
  • Stent if residual diameter stenosis <50%
  • Complications
    • Arterial spasm
    • Dissection
    • Arterial rupture
  • Post-procedure: Aspirin 3-6 months

Tullus et al. Renovascular hypertension in children. Lancet. 2008;371:1453-1463

angioplasty for renovascular hypertension in children 20 year experience
Angioplasty for renovascular hypertension in children: 20 year experience
  • Retrospective review from GOS
  • All children undergoing PTA 1984-2003
    • Only stenoses in main or large segmental arteries
    • Excluded transplants & inflammatory disorders
  • 33 children, 1.9-17.9 yrs (median 10.3)
    • 10 with underlying syndromes
    • 16 bilateral RAS
    • 15 intrarenal disease
  • 48 procedures, including 15 stents

Schroff et al. Pediatrics 2006;118:268-275

angioplasty for renovascular hypertension in children 20 year experience1
Angioplasty for renovascular hypertension in children: 20 year experience
  • Final outcomes of PTA:
    • 18 (55%) improved BP control
      • 11/13 (85%) if isolated main RAS
    • 10 (30%) ongoing HT despite adequate dilation
    • 5 (15%) PTA unsuccessful
    • Restenosis in 2/27 native renal arteries after balloon dilatation, 7/19 of stented arteries
    • 6 (18%) suffered complications, incl 1 death

Schroff et al. Pediatrics 2006;118:268-275

left ras before after angioplasty
Left RAS before & after Angioplasty

Schroff et al. Angioplasty for renovascular hypertension in children: 20 year experience. Pediatrics 2006;118:268-275

surgery
Surgery
  • For refractory HT when medical Rx & angioplasty have failed
  • Nephrectomy
  • Revascularisation procedures
  • Aortic reconstruction
results of surgical treatment for rvh in children 30 yr single centre experience
Results of surgical treatment for RVH in children: 30 yr single centre experience
  • 37 children (65% male)
  • 1979 - 2008
  • Mean SBP 140 (105-300) mmHg
  • 53 surgical procedures
    • Nephrectomy 18
    • Renovascular surgery 28
    • Aortic reconstruction 7

Stadermann et al. Nephrology Dialysis Transplantation. 2010;25(3):807-813

results of surgical treatment for rvh in children 30 yr single centre experience1
Results of surgical treatment for RVH in children: 30 yr single centre experience
  • 12 months post-op:
    • 16 (43%) normal BP without treatment
    • 15 (41%) normal/improved BP on 1-4 drugs
    • 4 (11%) unchanged
  • 90% overall improvement
  • Complications:
    • Haemorrhage (5)
    • Septicaemia (5)
    • Chylous ascites (1)

Stadermann et al. Nephrology Dialysis Transplantation. 2010;25(3):807-813

children not amenable to angioplasty or surgery
Children not amenable to Angioplasty or Surgery
  • Diffuse abnormalities of very small intrarenal arteries
  • Antihypertensive medication
    • Uncontrolled on 6-7 drugs not uncommon
  • Therapeutic trial with ACE inhibitor or angiotensin blocker warranted

Tullus et al. Renovascular hypertension in children. Lancet. 2008;371:1453-1463

our patient
Our Patient
  • 3 months post-angioplasty
  • BP well-controlled on 2 drugs
  • Close follow-up
    • BP
    • Renal function
    • DMSA
  • ? Consider cerebrovascular imaging