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A Case of Bilateral Renal Artery Stenosis

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A Case of Bilateral Renal Artery Stenosis

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

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