Your SlideShare is downloading. ×
A Case of Bilateral Renal Artery Stenosis
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

A Case of Bilateral Renal Artery Stenosis

3,174
views

Published on

Published in: Health & Medicine

0 Comments
3 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
3,174
On Slideshare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
79
Comments
0
Likes
3
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. A CASE OF UNEXPLAINED HYPOKALEMIA Prof.S.Sundar Unit Dr.R.Ganesan PG Internal medicine
  • 2. History
    • Breathlessness-6 hours
    • No h/o Chestpain
    • Palpitation
    • Cough&expectoration
    • Decreased urine output
    • Pedaledema
    • Abdominal distension
  • 3.
    • No h/o Facial puffiness
    • NSAID’S intake
    • Altered sensorium
    • Fever
    • Vomiting
    • Diarreha
  • 4. Past history
    • No past h/o similar episode
    • K/C DM-7 years on treatment
    • Not a k/c SHT/CAD/CKD/COPD
    • Married,having one daughter
    • Postmenopausel women
    • Non smoker,non alcoholic
  • 5. Examination
    • Conscious,oriented
    • Afebrile
    • Dyspnic,tachypnic
    • No pedaledema/ clubbing
    • No pallor/cyanosis
    • JVP not elevated
  • 6. Vitals
    • BP-250/150 mmhg
    • PR-98/m,Vessal wall thickend
    • RR-38/m
    • Carotid bruit +
  • 7.
    • CVS-S1,S2 +
    • ESM+ in AA
    • RS -NVBS +
    • B/L basal crepts +
    • P/A -Soft,no organomegaly, no FF
    • CNS- NFND
  • 8. Investigations
    • CBC:Hb-10g%
    • TC-6800cells/cmm
    • DC-P55%,L40%,E4%
    • Platelet-2lak/cmm
    • PCV-34%
    • Urea-38mg%,Createnine-0.9mg%
    • RBS-210mg%
  • 9.
    • Na-138meq/l, K-3.1meq/l
    • Urine r/e-normal
    • Urine ketons-negative
    • Urine c/s-no growth
    • 24 H urine protein-310mg
  • 10.
    • Lipid profile:T. CHO-210mg/dl
    • TGL-160mg/dl
    • LDL-155mg/dl
    • HDL-35mg/dl
    • VLDL-20mg/dl
  • 11.
    • ECG-Sinus tachycardia
    • CXR-S/O Pulmonaryedema
    • ECHO-Mild AS,
    • Concentric LVH
    • LVEF-60%
    • No RWMA
    • No AR
  • 12.
    • ABG-Normal
    • 24 H urine K-16meq
    • 24 H urine Ca-30meq
  • 13.
    • DIAGNOSIS-?
  • 14. USG KUB
    • RK-10×4.5cm,CMD+,normal echo
    • LK-4×2.8cm,contracted
  • 15. Renal artery doppler study RK PSV EDV RI Upper pole 184cm/s 29 0.6 Mid pole 153cm/s 10.3 0.8 Mesenchimal.A 186cm/s 22 0.7
  • 16. LK PSV EDV RI Upper P 184cm/s 7.3 0.7 Lower P 181cm/s 13.1 0.58 Mesenchimal A 179cm/s 15.5 0.8
  • 17. 64 Slice MD CT-Abdominal angiogram
    • Small LK with narrowing of origin and occlusion of left renal artery with distal reformation by retroperitoneal collaterals
    • Stenosis of origin of Right renal artery
    • Occlusive calcified atheromatous plaque of aorta
    • Multiple lumbar retroperitoneal collaterals
  • 18.  
  • 19.  
  • 20.  
  • 21.  
  • 22.  
  • 23.  
  • 24.
    • Bilateral Renal Artery Stenosis
  • 25. Treatment
    • Back rest
    • Nasal oxygen 6L/m
    • Ing.NTG 25micg/m
    • Ing.Frusemide 100mg stat
    • T.Amlodepine 2.5mg 4bd
    • T.Atenolol 50mg 2od
    • T.Methyldopa 250mg 2tid
    • T.Prazocin 2mg 2bd
  • 26.
    • T.Atarvostatin 10mg 4 HS
    • HA-8 IU tid
    • HM-10 IU bed time
  • 27. DEFINITION
    • Syndrome of elevated blood pressure produced by a variety of conditions that interfere with arterial circulation to kidney tissue
  • 28.  
  • 29. TWO KIDNEY HYPERTENSION
    • Unilateral ASRVD
    • Unilateral FMD
    • Renal artery aneurysm
    • Renal artery embolism
    • Traumatic arterial occlusion
    • Tumor compressing the artery
  • 30.  
  • 31.  
  • 32. ONE KIDNEY HYPERTENSION
    • Bilateral renal artery stenosis
    • Stenosis of solitaryfunctioning kidney
    • Coarctation of aorta
    • Takayasu’s disease
    • Polyarteritis nodosa
  • 33.  
  • 34.  
  • 35.  
  • 36. TAKAYASU’S ARTERITIS
    • Most common in Asia
    • Female to male ratio-9:1
    • Age of presentation 10-20 years
    • Strong predilectoin of aortic arch and it’s branches-AORTIC ARCH SYNDROME
  • 37. Scenarios in RA stenosis and hypertension
    • True RVH
    • Pure essential hypertension in which RA stenosis is present but not contribute to hypertension
    • Essential hypertension with superimposed RA stenosis in which RA stenosis contribute to essential HT
    • RA stenosis leads to ischemic renal disease
  • 38. CLINICAL FEATURES
    • Abdominal bruit
    • Hypokalemia
    • Family h/o hypertension-abscent
    • Early onset<30 years
    • Late onset>50 years
    • Flash pulmonary edema
  • 39.
    • Nephrotic-range proteinuria
    • Acute renal failure during treatment of hypertension
    • Progressive renal failure
  • 40. NONINVASIVE SCREENING TESTS
    • Magnetic resonance angiography
    • CT Angiography
    • Renal duplex sonography
  • 41. MRA
    • Best screening test
    • Sensitivity 92%-100%
    • Specificity 69%-95%
    • Negative predictive value 100%
    • Over estimate the degree stenosis mid to distal renal artery
    • Accessory renal artery may be missed
  • 42. CT-Angiography
    • Similar sensitivity&specificity of MRA
    • Proven useful in restenosis of stented renal artery
    • Requiring intravenous radiocontrast
  • 43.  
  • 44.  
  • 45.  
  • 46. Renal duplex sonography
    • Proximal criteria
    • 1.Peak systolic velocity>200cm/sec
    • 2.Ratio of PSV in renal.A to aorta>3.5
    • 3.Turbulent flow in poststenotic region
    • 4.Lack of detectable doppler signal in a visualized renal artery
  • 47. Distel criteria
    • Loss of early systolic peak
    • Slope of the systolic upstroke<300cm/sec
    • Acceleratioon time>0.07sec
    • Resistive index change of >5% between right&left kidney
  • 48. RESISTIVE INDEX
    • RI=[PSV-EDV]/PSV
    • Predict renal function &BP response to renal revascularisation
    • RI>0.8 poor chance of improvement
  • 49.
    • Sensitivity 66%-100%
    • Specificity 67%-94%
    • Operator dependency
    • Patient factors-habitus, echogenisity of fascia,depth,angle of artery, bowel gas interference
  • 50. OTHER SCREENING TESTS
    • Captopril renography- accurate for RVH but not accurate in renal insufficiency
    • Renal vein renin- not useful in bilateral renal disease
    • Isotopic renal blood flow and functional scans-not useful in bilateral renal disease
  • 51. Angiography-Goldstandard TEST CONTRAST ARTERIAL PUNCTURE RISK OF EMBOLI QUALITY OF IMAGE CONVENTIONAL ++ YES +++ +++ INTRAVENOUS SUBSTRACTION +++ NO NO + INTRAARTERIAL SUBSTRACTION + YES ++ ++ CO2 NON YES +++ +
  • 52. MANAGEMENT OPTIONS
    • Medical management
    • PTRA
    • PTRA with endovascular stent
    • Primary renal artery stenting
    • Surgical revascularisation
  • 53. Medical management
    • Optimizing the blood pressure
    • Treatment of hyperlipidemia
    • Cessation of smoking
    • Control of diabetes
    • Management of CKD
    • Careful followup at 4-6months intervel for change in renal function&size
  • 54. INDICATIONS FOR REVASCULARIZATION
    • Uncontroled BP inspite fo maximal drug therapy
    • Prograssive rise in creatinine[other causes excluded]
    • Intolerance to ACE-Is,ARBs[>30% increase in creatinine,severe hyperkalemia]
    • Recurrent pulmonary edema,CHF
  • 55.  
  • 56. PTRA
    • Proved successful in fibro muscular dysplasia and ASRVD
    • Success rate75%-80%
    • PTRA alone high early restenosis rate upto 30%at 6-12 months
    • Low success rate with ostial disease,diffuse&large lesion, totally occluded vessel
  • 57. Renal complications of PTRA
    • Haematoma
    • Haemorrhage
    • Pseudoaneuysm or dissection of access vessel
    • Dissection & rupture of renal artery
    • Renal artery thrombosis
    • Acute renal failure
    • Distal cholestrol embolism
  • 58. ENDOVASCULAR STENTS
    • Preferred renal artery revascularization in most the centers
    • Higher risk for renal.A dissection,rupture and thrombosis
    • Most of the restenosis occur in first 6months of intervention,common in smaller vesels
  • 59. Indicators of restenosis
    • Worsening of blood pressure
    • Worsening of renal function
    • Silent renal atrophy
  • 60. Surgical revascularisation
    • Replaced by endovascular stents
    • Excellent long term patency rate-93%
    • Predictors of good outcome
    • Lower preoperative S.creatinine-2mg
    • Bilateral renovascular disease
    • Recent rapid decline of renal function
  • 61.
    • Aortorenal bypass: autogenous or
    • synthetic graft
    • Extra-anatomic bypass: splenorenal
    • hepatorenal
    • ileorenal
    • Supradiaphragmatic,supraceliac and thoracic aortorenal bypass
    • Transaortic renal endarterectomy
  • 62. Transplant renal artery stenosis
    • Transplant RA stenosis Commonly occurs period between 3months to 2years after transplantation
    • Use of pediatric kidney to adult recipients high risk for stenosis
    • Pseudotransplant RA stenosis- vascular disease proximal to allograft artery
  • 63. Causes
    • Commonly associated with end to end anastomoses
    • CMV infection
    • Calcineurin inhibitor toxicity
    • Chronic rejection
  • 64.
    • Systolic bruits over transplant is not diagnostic
    • RDS is screening test of choice
    • PTRA or surgical revasularisation
  • 65. Hypertension Sus of RVH Medical Rx ,Follow-up Low suspicious High suspicious Medical Rx ,Follow-up Good BP control? Stable Renal Func ? yes No Candidate for revascularization Renal Func unstable or at risk Non invasive study Angiography Surgical revas PTRA with Stent Medical Rx ,Follow-up yes positive No negative Positive high grade lesion
  • 66.
    • Subclavian.A-93%
    • Common carotid.A-58%
    • Abdominal aorta-47%
    • Renal.A-38%
    • Aortic arch and it’s roots-35%
    • Vertibral.A-35%
  • 67.
    • Panarteritis: intimal proliferation,medial fibrosis and scarring,degeneration of elasticlamina
    • Polymyalgiarheumatica absente
    • RVH occur32%to 93%
  • 68.  
  • 69. Pathophysiology
    • Activation of RAS
    • Intrarenal activation of sympathetic nervous system
    • Impairment of NO generation
    • Release of endothelin
    • Hypertensive microvascular injury to nonstenosed kidney
  • 70.  
  • 71. Renal toxicity with ACE-Is
    • Predisposing condtions
    • 1.Bilateral RA stenosis
    • 2.Solitary functioning kidney
    • 3.Widespread atherosclerosis
    • 4.Impaired pretreatment renalfunction
  • 72.
    • 5. Diuretic therapy
    • 6.Volume losses: vomiting,diarrhea
    • 7.NSAIDs
    • 8.Low sodium intake
  • 73.  
  • 74.  

×