Topic: Renovascular diseases Faculty: Medicine Course: BSc RDT - 2nd year - Renal artery stenosis - Renovascular hypertension: Benign and malignant nephrosclerosis - Hemolytic uremic syndrome - Thrombotic thrombocytopenic purpura - Renal vein thrombosis

1. Renovascular diseases
Dr. Salman Ansari
Kanachur Institute of Medical Sciences

2. Contents
● Renal artery stenosis
● Renovascular hypertension
● Hemolytic uremic syndrome
● Thrombotic thrombocytopenic purpura
● Renal vein thrombosis

3. Renal artery stenosis
Definition: narrowing of one or both renal arteries
>70% narrowing is associated with reduction of blood flow
to kidneys

4. Causes
● Atherosclerosis (most common cause).
● Fibromuscular dysplasia.
● Vasculitis

6. Clinical features
● Hypertension: if RAS is unilateral
● Renal failure: if RAS is bilateral
● Vascular disease in other parts such as legs
● Worsening of renal function after starting ACE inhibitors
● Repeated pulmonary edema

7. Investigations
● RFT
● USG abdomen: asymmetry in kidney size in unilateral RAS
and bilateral shrunken kidneys in bilateral RAS.
● Renal artery doppler
● Renal arteriography: gold standard

8. Treatment
Observation if stenosis <80%
● Strict control of serum cholesterol, with the use of statins
● correction of dyslipidemia, anti-platelet drugs, and control of
hypertension
If stenosis >80%: revascularisation with stent placement

9. Renovascular hypertension
or
Effects of hypertension on kidney

10. Renovascular hypertension
- Common cause of secondary hypertension
- Due to narrowing of blood vessels in kidney

11. 2 conditions:
- Benign nephrosclerosis
- Malignant/hypertensive nephrosclerosis

12. Benign nephrosclerosis
Renal changes most commonly occurring in association with
long-standing hypertension
- Called benign because it does not usually progress to CKD

13. Causes
● Renal artery stenosis (RAS), mostly secondary to
atherosclerosis
● Fibromuscular dysplasia (FMD)
● Takayasu arteritis
● Extrinsic compression of a renal artery

14. Clinical features
● Resistant hypertension: Uncontrolled blood pressure which
needs 2 or 3 antihypertensive agents of different classes
● History of multiple hospital admissions for hypertensive crisis
● Elevation in creatinine of more than 30% after starting an
angiotensin-converting enzyme inhibitor (ACE-I)
● Unilateral small or atrophic kidney

15. Investigations
● Urine analysis: proteinuria
● RFT
● Imaging: duplex ultrasonography, renal arteriography
● Atrophic kidney

16. Management
● Treat underlying cause
● Medical management with antihypertensives:
● 2 medications required usually
● ACE inhibitors/ARB, plus CCB/thiazide
diuretic/beta-blocker
● In bilateral lesions or single functional kidney:
ACEI/ARBs to be AVOIDED
● Percutaneous angioplasty, with placement of stents.
● Renal bypass surgery

18. HYPERTENSIVE NEPHROSCLEROSIS

19. Hypertensive nephrosclerosis
Definition: progressive kidney damage caused by long-
standing, poorly controlled high blood pressure
Etiology:
- Due to chronic hypertension
- It leads to end stage kidney disease

20. Clinical features
- SBP >200 mmHg
- DBP >120 mmHg
- Papilledema, retinal hemorrhage, renal failure
- Initially, headaches, nausea, vomiting, problems with vision
- Later renal failure may develop
- Features of chronic kidney disease

21. Investigations:
Routine blood tests, RFT, imaging
Treatment:
● Strict control of BP
● Weight loss, exercise, and salt and water restriction also
help control blood pressure
● Dialysis if needed

22. HEMOLYTIC UREMIC SYNDROME

23. Hemolytic uremic syndrome(HUS)
Syndrome of thrombocytopenia, hemolytic anemia and acute
kidney injury
Causes:
- Shiga toxin
- Less common: genetic abnormality of complement

24. 2 types:
- Typical or diarrhoea-associated HUS: D+ HUS
- Atypical or D- HUS

25. Clinical features:
- Child < 5 years: painful diarrhoea, cramping, fever,
vomiting
- Renal symptoms: anuria, oliguria
- Skin petechiae, easy bleeding

26. Treatment:
- Supportive treatment - dialysis
- AVOID antibiotics
- Fresh frozen plasma exchange

27. THROMBOTIC THROMBOCYTOPENIC
PURPURA

28. Thrombotic thrombocytopenic purpura
Pentad of:
1. Fever
2. Hemolytic anemia
3. Thrombocytopenia
4. Renal dysfunction
5. Neurologic dysfunction
Cause: decrease in ADAMTS13(enzyme which breaks
von Willebrand factor), leading to formation of microthrombi

29. Clinical features:
- Mainly neurologic symptoms like headache,
neurologic deficit, seizure, confusion
- Abdominal pain
- Bleeding or purpura
- All 5 features of pentad are not always seen - only in
<5% of cases

30. Investigations:
● Anemia, thrombocytopenia
● Low level of ADAMTS13 assay
Treatment:
Plasma exchange(PEX), with high-dose corticosteroid
therapy

31. RENAL VEIN THROMBOSIS

32. Renal vein thrombosis
Presence of thrombus in major renal veins or its tributaries
It is rare
Causes:
● Associated with nephrotic syndrome, malignancy, external
compression, hypercoagulability disorders
● Virchow’s triad

33. Clinical features:
- Acute: flank pain, sudden deterioration of renal function,
proteinuria, hematuria
- Chronic: asymptomatic
Investigations:
● Renal venography
● Renal USG

34. Treatment:
● Treat the underlying cause(usually nephrotic
syndrome)
● Support kidney function
● Anticoagulation therapy to prevent recurrence

35. Questions
LE: effects of HTN on kidney
SE: RAS
SA:
- atherosclerotic renal disease
- management of renal HTN

36. References:
● Renovascular Hypertension - StatPearls
● Renal Artery Stenosis - StatPearls
Questions:
salman.s.ansari92@gmail.com
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