Clinical quiz. Bilateral renal artery stenosis

Bilateral Renal Artery Stenosis with Abdominal Aorta Coarctation in a Child with Severe Hypertension

This report describes the clinical course, diagnostic evaluation, and management of a 12-year-old child with bilateral renal artery stenosis (RAS) and concurrent narrowing of the abdominal aorta. The child was presented with a 2-day history of headache, vomiting, seizures, and right hemiparesis with normal findings from fundoscopic examination. There were no clinical or laboratory features suggesting the etiology of hypertension, nor had there been any diagnostic procedures in screening for hypertension due to bilateral RAS. Abdominal aortography confirmed the diagnosis of bilateral RAS and abdominal aorta coarctation. The hypertension was severe and resistant to combination of several antihypertensive agents. Aortobilateral renal bypass with autogenous saphenous grafts and midaortic angioplasty with polytetrafluoroethylene (PTFE) was performed. Histopathologic studies revealed subintimal fibrosis.

Evaluation and management of bilateral renal artery stenosis in children: a case series and review

This report describes the clinical course, diagnostic evaluation and management of six children with bilateral renal artery stenosis (RAS) and concurrent narrowing of the abdominal aorta. Except for one child with active arteritis, the others were asymptomatic. There were no clinical or laboratory features suggesting the etiology of hypertension in four of six patients, and diagnostic procedures, including Doppler duplex ultrasound and captopril scintigraphy, were unreliable in screening for such hypertension. Abdominal aortography and selective renal angiography confirmed the diagnosis of bilateral RAS and associated anatomical alterations of the aorta and its branches. The hypertension was severe and minimally responsive to antihypertensive agents. It was cured or improved after percutaneous transluminal angioplasty (PTA) of three vessels in two children with mid-vessel stenoses, while hypertension persisted after PTA of two mid-vessel stenoses in a third child and one vessel with ostium stenosis in a fourth child. Autotransplantation of seven kidneys in four children resulted in cure of significant improvement of the hypertension. Renal function was preserved in all children during a mean follow-up time of 41 months. Based on illustrative data from these six children, as well as information from a review of the literature, this report discusses the key diagnostic issues and stresses the potential advantages of renal autotransplantation in selected children with this disorder.

Renovascular hypertension in children

Renal arteriography remains the only study to identify and define correctly both location and extent of renal artery stenosis. Because other studies do not adequately identify all children who have renal artery disease, it is reasonable to perform renal arteriography in those children with severe hypertension who do not have another readily identifiable cause for their hypertension. On the other hand, in children with less profound elevation of blood pressure in whom there is no other definable cause, it is possible to defer renal angiography. In these children with mild or moderate hypertension, studies such as the captopril 99mTc-DTPA scan or intravenous digital subtraction angiography may identify those for whom arteriography is more likely to have abnormal results.