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(a) MR Angiogram of High grade renal artery stenosis with renal vein renin measurements: lateralization suggests high probability of pressor activity. (b) Renal artery duplex study of distal segments on the right kidney illustrating "parvus tardus" waveform and low resistive index (RI=0.42). These data suggest excellent distal blood flow "runoff' and limited parenchymal fibrosis. Severe hypertension had developed over a three month period that was reversed by successful revascularization. (c) Manifestations of renal arterial disease
Source publication
Renovascular disease remains among the most prevalent and important causes of secondary hypertension and renal dysfunction. Many lesions reduce perfusion pressure including fibromuscular diseases and renal infarction, but most are caused by atherosclerotic disease. Epidemiologic studies establish a strong association between atherosclerotic renal-a...
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Background:
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Citations
... Renal parenchyma loss remains the main cause of renal function decline post-PN, but renal ischemia secondary to renal artery clamping during surgery is also a contributing factor, with prolonged ischemia time associated with more postoperative renal function decline [23,24]. Diabetes has been demonstrated to increase reperfusion injury following ischemia in a rodent model [25] and whilst the aetiopathogenesis of renal failure in the setting of hypertension following renal artery clamping is less clear, there are well appreciated complex interactions between hypertension and renal ischemia [26]. By comparison, radiation nephropathy results in cell death through the dose-dependent creation of double-stranded DNA breaks [27]. ...
Background
Stereotactic ablative body radiotherapy (SABR) is an emerging treatment for patients with primary renal cell carcinoma (RCC). However, its impact on renal function is unclear. This study aimed to evaluate incidence and clinical factors predictive of severe to end-stage chronic kidney disease (CKD) after SABR for RCC.
Methods and materials
This was a Single institutional retrospective analysis of patients with diagnosed primary RCC receiving SABR between 2012–2020. Adult patients with no metastatic disease, baseline estimated glomerular filtration rate (eGFR) of ≥ 30 ml/min/1.73 m², and at least one post-SABR eGFR at six months or later were included in this analysis. Patients with upper tract urothelial carcinoma were excluded. Primary outcome was freedom from severe to end-stage CKD, determined using the Kaplan–Meier estimator. The impact of baseline CKD, age, hypertension, diabetes, tumor size and fractionation schedule were assessed by Cox proportional hazard models.
Results
Seventy-eight consecutive patients were included, with median age of 77.8 years (IQR 70–83), tumor size of 4.5 cm (IQR 3.9–5.8) and follow-up of 42.2 months (IQR 23–60). Baseline median eGFR was 58 mls/min; 55% (n = 43) of patients had baseline CKD stage 3 and the remainder stage 1–2. By last follow-up, 1/35 (2.8%) of baseline CKD 1–2, 7/27 (25.9%) CKD 3a and 11/16 (68.8%) CKD 3b had developed CKD stage 4–5. The estimated probability of freedom from CKD stage 4–5 at 1 and 5 years was 89.6% (CI 83.0–97.6) and 65% (CI 51.4–81.7) respectively. On univariable analysis, worse baseline CKD (p < 0.0001) and multi-fraction SABR (p = 0.005) were predictive for development of stage 4–5 CKD though only the former remained significant in multivariable model.
Conclusion
In this elderly cohort with pre-existing renal dysfunction, SABR achieved satisfactory nephron sparing with acceptable rates of severe to end-stage CKD. It can be an attractive option in patients who are medically inoperable.
... 1,2 When atherosclerosis does occur in the juxta-and suprarenal segments, it tends to occur at the ostia and proximal regions of the renal and visceral vasculature. 3 When symptomatic, these isolated lesions are often amenable to an endovascular approach. 4,5 A small proportion of disease, however, evolves into large exophytic intra-aortic plaques, which preclude an endovascular approach. ...
Coral reef atherosclerosis of the paravisceral aorta is a rare disease whose description is confined to before contemporary vascular surgical techniques. This study aims to describe the characteristics and outcomes of patients with coral reef aorta treated with trapdoor endarterectomy at a single high-volume quaternary referral center since 2010. From 2010 to 2022, 14 patients with coral reef aorta were treated with trapdoor endarterectomy. The patient data were obtained via a retrospective medical record review. The patients were predominantly women (79%) with a median age of 65 years (interquartile range [IQR], 60-70 years). The patients universally had a tobacco smoking history and hypertension. More than 85% had previously diagnosed carotid stenosis. Two patients (14%) had undergone prior aortofemoral reconstruction, and one patient (7%) had undergone prior axillobifemoral bypass. The most common presenting symptoms were claudication (71%), chronic mesenteric ischemia (50%), and renovascular hypertension (43%). Of the 14 patients, 8 (57%) underwent isolated endarterectomy and 6 (43%) underwent concomitant aortobifemoral bypass. In addition, 13 patients (93%) required a supraceliac aortic clamp position with a median clamp time of 23 minutes (IQR, 20-30 minutes). The median estimated blood loss was 1650 mL (IQR, 1025-3000 mL). A cell saver was used in 13 procedures (93%), with a median transfusion of 563 mL (IQR, 231-900 mL). The median operative time was 341 minutes (IQR, 315-416 minutes). Eight patients (57%) experienced acute kidney injury in the postoperative period with a peak creatinine of 1.96 mg/dL (IQR, 1.50-2.84 mg/dL). The median length of stay was 11 days (IQR, 6-16 days), with an intensive care unit stay of 4 days (IQR, 2-7 days). One patient (7%) required reoperation in the immediate perioperative period for a retroperitoneal hematoma. The postoperative ankle brachial index increased from a median of 0.58 (right) and 0.57 (left) bilaterally in the preoperative period to 1.09 (right) and 1.10 (left) postoperatively. Eight patients (57%) had follow-up data available for >2 years postoperatively, with five patients (36%) having follow-up data available for >3 years. Two major adverse cardiac events were reported at the last follow-up. One patient reported mild recurrent symptoms of chronic mesenteric ischemia during 3 years of postoperatively, with no concurrent imaging findings or loss of patency found on computed tomography angiography. Symptomatic coral reef atherosclerosis of the paravisceral aorta is a complex disease rarely encountered even at high-volume referral centers. These patients can be expected to experience short-term postoperative morbidity and require intensive care. Despite these challenges, trapdoor endarterectomy is a safe and effective procedure for coral reef aorta, and most patients achieve dramatic symptomatic improvement with durable results.
... It accounts for less than 1% of cases of mild to moderate systemic hypertension, but it is found more commonly among patients with severe, refractory systemic hypertension and in those with systemic hypertension diagnosed at a young age who have no family history of primary hypertension. 1,2 Renal DUS is accurate as the initial screening method for renovascular hypertension. Direct visualization of the main renal arteries using B-mode imaging combined with Doppler spectral waveform measurements can be used to detect, localize, and quantify stenotic lesions in native renal arteries. ...
Renal artery duplex ultrasound has been very successful in assessing renovascular hypertension. When renal artery velocities are within normal limits, but the Doppler spectral waveform is of small amplitude with a prolonged systolic rise, a more proximal arterial stenosis is suspected. We describe 2 cases of coarctation of the aorta in adults that were diagnosed with the assistance of aortic and renal artery duplex ultrasound.
... En cuanto a las técnicas de imagen para confirmar la sospecha de estenosis renal están la ecografía bidimensional y el estudio Doppler como técnicas simples, no invasivas y bien toleradas por los niños, los mismos que tienen una sensibilidad entre el 65% y 85% 5 , se considera que el resultado es positivo cuando se evidencia estrechez de la luz del vaso mayor al 60%, se evidencia curva espectral distal característica tipo tardus parvus y parámetros de flujo dependientes de la edad (velocidad sistólica máxima mayor a 200 cm/s) 4 . Hay que considerar que hasta el 20% de los estudios son técnicamente insatisfactorios, lo que puede limitar su aplicación 3,19 . ...
Introducción: la hipertensión renovascular, resultado de estenosis arterial renal, es poco común en niños. Durante el diagnóstico, el cateterismo puede ser además método terapéutico. El objetivo es presentar el caso de un paciente pediátrico tratado percutáneamente. Caso clínico: adolescente con hipertensión arterial refractaria tratado con varios medicamentos durante dos años; aunque las imágenes no invasivas no fueron concluyentes se sospechó de etiología renovascular; la angiografía por cateterismo identificó estenosis renal en la arteria segmentaria inferior derecha que fue tratada mediante angioplastia con balón sin complicaciones; la presión arterial disminuyó a valores normales y durante 22 meses de seguimiento el paciente se mantiene sin medicación y estable. Conclusiones: la angioplastia renal percutánea con balón en el paciente resolvió la hipertensión renovascular de forma segura y efectiva.
... Он, в свою очередь, являясь мощным вазоконстриктором, способствует увеличению секреции альдостерона, задержке натрия и воды в организме и в конечном итоге приводит к повышению АД. Определенное значение в патогенезе реноваскулярной АГ придают также снижению уровня некоторых депрессорных и вазодилататорных веществ, вырабатываемых почками (простагландины, кинины и др.) [22,23,24]. ...
The clinical significance of renovascular arterial hypertension is determined by it is high prevalence as well as it is negative impact on prognosis. The most common causes of renovascular arterial hypertension are atherosclerotic stenosis of the renal arteries and fibromuscular dysplasia. Renovascular arterial hypertension is characterized by the development of blood pressure resistant to antihypertensive therapy with an unfavorable prognosis of worsening renal function and cardiovascular complications. Currently, the most available screening method in the diagnosis of renovascular arterial hypertension is duplex scanning of the renal arteries. Non-invasive diagnostic methods also include magnetic resonance and multispiral computed tomography with intravenous contrast. Contrast angiography remains “the golden standard” for diagnosing renovascular arterial hypertension and determining the indications for surgical treatment. Together with the use of diagnostic techniques such as measurement of translesion pressure gradient and fractional blood flow reserve, it allows to assess the functional significance of renal artery stenosis. Treatment of renovascular arterial hypertension is a complex process aimed at normalization of blood pressure, improvement of renal function, as well as mortality and cardiovascular risk reduction. To date, the feasibility of endovascular treatment remains an open question. More often the preference is given to conservative treatment. The indications for renal artery revascularization are less obvious, available clinical guidelines and results of large trials are controversial.
... В ответ на гипоперфузию активируется симпатическая нервная система и РААС, синтез простагландинов, оксида азота, что, в свою очередь, снижает экскрецию натрия и вызывает вазоконстрикцию [29]. Нарушение почечной перфузии приводит к микрососудистой дисфункции и интерстициальному фиброзу [30]. Контралатеральная почка противодействует данным изменениям прессорным натриурезом [31]. ...
Arterial hypertension is both the cause and the result of the progression of chronic kidney disease, which affects about 10-15% of the population worldwide and the prevalence of which is steadily increasing. As the glomerular filtration rate decreases, the blood pressure level rises respectively. Arterial hypertension (AH) and chronic kidney disease (CKD) are independent and well-known risk factors for the development of cardiovascular diseases, and their combination significantly increases the incidence and mortality from cardiovascular disease. Blood pressure control is the most important factor in slowing the progression of CKD and reducing cardiovascular risk. Currently, there is a place for discussions in the scientific community regarding the target blood pressure levels in patients suffering from CKD. Non-pharmacological methods of treatment can reduce the level of blood pressure in some cases, but do not help to achieve the target values in most of the cases. Patients with hypertension and CKD need combined drug therapy. Certain modern drugs have additional cardio- and nephroprotective properties and should be considered as the first line of therapy. A personalized approach based on evidence-based principles makes it possible to achieve blood pressure control, reducing cardiovascular risk and slowing the progression of CKD. This consensus summarizes the current literature data, as well as highlights the main approaches to the management of patients with hypertension and CKD.
... The result is profound angiotensin-mediated vasoconstriction and aldosterone-induced sodium and water retention. The ensuing cascade of events varies, depending on the presence of a functioning contralateral kidney [5]. When two kidneys are present, aldosterone-mediated sodium and water retention is handled properly by the nonstenotic kidney, precluding volume from contributing to angiotensin II-mediated hypertension. ...
Background:
Secondary hypertension is a relatively rare condition most commonly caused by renovascular disease due to atherosclerotic vascular disease or fibromuscular dysplasia. Although accessory renal arteries are frequent, to date, only six cases of secondary hypertension determined by their existence have been reported.
Case summary:
We describe a case of a 39-year-old female who came to the emergency department with an urgent hypertensive crisis and hypertensive encephalopathy. Despite normal renal arteries, the computed tomography angiography revealed an inferior polar artery with 50% stenosis of its diameter. Conservative treatment with amlodipine, indapamide and perindopril was adopted, leading to blood pressure control within one month.
Conclusion:
To the best of our knowledge, there are controversies regarding accessory renal arteries as a potential etiology for secondary hypertension, but the seven similar cases already described, along with the current case, could reinforce the necessity of more studies concerning this subject.
... The span of severity of renal ischemia varies in relation to the extension of intrarenal damage and vascular rarefaction. Several studies indicate that chronic renal vascular obstruction can trigger a pathological cascade characterized by hypoxia, inflammation, microvascular rarefaction, and fibrosis [5]. Fibrotic parenchymal substitution occurs in the long-term and is an irreversible condition that questions the success of revascularization procedures [6]. ...
... The correlation between reduced renal blood flow (RBF) and parenchymal oxidative and inflammatory damage in renal atherosclerosis is still poorly understood. Some authors suggest hypoxia as the trigger of a "common pathway" leading to renal fibrosis substitution after tubulo-glomerular damage [2,5]. This depends on the enhanced oxygen consumption by the kidney with the adaptative increase in RBF. ...
... As reported by several authors, in ischemic nephropathy, the rarefaction of the vascular bed is always present, but with variable severity. In fact, a stable 30-40% reduction in renal blood flow (RBF) is associated with unchanged intrarenal oxygenation after PTRA [5,7]. This partly depends on compensation due to altered shunting. ...
Ischemic nephropathy consists of progressive renal function loss due to renal hypoxia, inflammation, microvascular rarefaction, and fibrosis. We provide a literature review focused on kidney hypoperfusion-dependent inflammation and its influence on renal tissue’s ability to self-regenerate. Moreover, an overview of the advances in regenerative therapy with mesenchymal stem cell (MSC) infusion is provided. Based on our search, we can point out the following conclusions: 1. endovascular reperfusion is the gold-standard therapy for RAS, but its success mostly depends on treatment timeliness and a preserved downstream vascular bed; 2. anti-RAAS drugs, SGLT2 inhibitors, and/or anti-endothelin agents are especially recommended for patients with renal ischemia who are not eligible for endovascular reperfusion for slowing renal damage progression; 3. TGF-β, MCP-1, VEGF, and NGAL assays, along with BOLD MRI, should be extended in clinical practice and applied to a pre- and post-revascularization protocols; 4. MSC infusion appears effective in renal regeneration and could represent a revolutionary treatment for patients with fibrotic evolution of renal ischemia.
... In children up to 16 years of age, the definition of arterial hypertension (AH) is arbitrary and implies systolic and/ or diastolic blood pressure ≥ 95 th percentile for sex, age and body height, and in adolescents over 16 year of age, it is an absolute value of blood pressure ≥ 140/90 mmHg, in three separate measurements (1). The prevalence of AH in children is between 2 and 4% (2). ...
... Therefore, it is extremely important to diagnose AH in children, find its cause and provide an adequate treatment. RVH occurs as a result of reduced blood flow through one or both renal arteries due to their narrowing, which results in the activation of the renin-angiotensin-aldosterone system (16). Increased blood pressure is a compensatory mechanism that enables blood flow through a narrowed RBV, but over time it also leads to the damage of the target organ. ...
Introduction: Renal blood vessel (RBV) stenosis is the cause of secondary arterial hypertension (AH) in 10% of children. Digital subtraction angiography (DSA) is the gold standard in diagnosing RBV stenosis. Many authors suggest Mr angiography (MRA), a non-invasive method without radiation, as an adequate diagnostic method. Our aim was to analyze the experience of our center in using MRA in children with AH. Method: This retrospective study included 148 patients hospitalized at the University Children's Hospital in Belgrade, due to AH. After initial examination, patients underwent DSA and/or MRA. Results: According to the current guidelines, DSA was performed in patients with highly suspected RBV stenosis, and the diagnosis was confirmed in 13/29 (45%). Diagnostic MRA was done in 116/119 (97.5%) patients, and control MRA was done after therapeutic revascularization in 3/119 (2.5%). In 4/116 (3.5%) patients, the findings indicated RBV stenosis, and in 44/116 (38%) it indicated some other abnormality of the kidney parenchyma and the urinary tract or RBV varieties. After MRA, DSA was performed in 7/116 (6%) patients (4 with RBV stenosis on MRA and 3 with clinical suspicion of RBV stenosis), but all findings were normal. Conclusion: According to the results, it is justified to perform a diagnostic MRA before DSA in children with highly suspected RBV stenosis, in order to avoid DSA which is an invasive procedure with radiation, in some patients with normal findings. Also, over time, we would have a clearer view of the sensitivity and specificity of MRA as a diagnostic method in RBV stenosis in children.
... One study has reported that 18.9% of children with HTN-C were caused by RAS [12]. The incidence of RVH in both adults and pediatrics is about 5%-10% [8,13]. The difference between RVH and other causes of hypertension is that RVH can be cured by medication, intravascular intervention or surgery. ...
Background
Renovascular hypertension (RVH) is one of the main causes of hypertensive crisis (HTN-C). It is characterized by acute onset and severe disease, and early diagnosis and treatment are difficult. The objective was to describe the characteristics of RVH and factors associated with RVH leading to HTN-C in children. At present, there are few clinical studies on RVH in children with large cases in China.
Methods
This study retrospectively analyzed the clinical data of inpatient children with RVH. Patients were divided into non-hypertensive crisis (non-HTN-C) group, and HTN-C group according to the first symptoms and blood pressure. Further, HTN-C were classified as hypertensive urgency (HTN-U) or hypertensive emergency (HTN-E).
Results
Fifty-four pediatric cases (41 boys and 13 girls) were included. 83.3% of the RVH cases were ≥ 6 years old. Three cases were classified into the non-HTN-C group. Of the 51 HTN-C cases, 18 cases wer e grouped as HTN-U and 33 as HTN-E. The HTN-U group were mainly asymptomatic (50.0%, 9/18) while the HTN-E group mainly presented with neurological symptoms (72.7%, 24/33). The number of unknown etiology children was 32 (59.2%). The top three known etiologies were Takayasu’s arteritis (50.0%, 11/22), congenital renal dysplasia (27.3%, 6/22) and fibromuscular dysplasia (13.6%, 3/22). As for the target organ damage of RVH, patients had a higher prevalence of left ventricular hypertrophy (71.4%, 35/49) and retinopathy (77.8%, 21/27).
Conclusions
Most RVH patients with HTN-C as the first symptoms, especially for males over 6 years old, should be assessed for RVH even if they were asymptomatic. Most asymptomatic patients with RVH already had target organ damage, and symptomatic patients even developed life-threatening complications. As preventive measures, routine monitoring of BP during children’s physical examinations is advised.
