Picture 1 A,B:

Vľavo: CT nález – atrofia pravej obličky, Vpravo – plazmatická renínová aktivita zo samplingu venóznej krvi z v. cava inferior a renálnych vén.

Authors:

• Ivar Vacula, MD, PhD.
  Outpatient Angiological Clinic, Trnava
• Juraj Maďarič, MD, PhD, MPH
  Angiological clinic of the Faculty of medicine, Comenius University, National Institute for Cardiovascular diseases, Bratislava
• Marián Cvik, MD, PhD.
  Urological Clinic, Faculty Hospital, Trnava

Case report

70 years old normostenic female patient, smoker, with the history of arterial hypertension, dyslipoproteinemia, seropositive oligoarthritis, after the carotid artery endarterectomy due to severe stenosis and reversible ischemic neurological deficit (2001), was presented at our outpatient clinic in June 2021 because of refractory arterial hypertension. Blood pressure values were repeatedly over 210/110mmHg from december 2020, despite of the six combination of the antihypertension drugs used: hydrochlorothiazid, quinapril, rilmenidin, bisoprolol, nitrendipin, urapidil. The serum creatinin values were stabilized for almost two last years at the level od 110umol/l. Ultrasound examination of the abdomen revealed seriously atrophic right kidney with the longitudinal diamter less than 70mm, with preobliterative stenosis of the renal artery (confirmed by CT angiogram – Picture 1A). Renal scintigrafy concluded afunctional kidney, thus the renal revascularization was no longer in consideration.

After the consilium with urologist and nephrologist, the cathetrization and sampling of the plasmatic renal activity from both renal veins, left suprarenal vein and inferior cava was performed. (Picture 1B) with the aim to confirm or exclude hormonal activity of the afunctional kidney. The result – plasmatic renin activity (PRA) from right renal vein (VR l. dxt.) vs. Value from the left renal vein (VR l. sin.) – ratio 4,49 as well as the clear difference in the ratio PRA VR l. dxt./VCI vs. VR l. sin/VCI (3,33 vs. 0,87; ratio 3,8) were interpreted as highly suspicious renovascular influence in the etiology of the refractory hypertension. Our consiliary decision was indication of the laparoscopic nephrectomy of the right kidney – realized in january 2022. Histopathologic examination of the excisions confirmed arterionephrosclerosis. Further monitoring of the blood pressure lead to the reduction of the medication to twocombination of antihypertensive drugs – amlodipín (10mg) and perindopril (10mg) with the achievement of the target values of the blood presuure lower than 140/90mmHg.

Discussion

Although some case series with patients suffering from atherosclerotic renal artery stenosis (ARAS) showed at least partially consistent favourable effect of the interventional or surgical renal revascularization on the blood pressure control^1,2, prospective well controlled studies have had less unequivocal or even ambigous  results regarding all of the aims of the revascularization – blood pressure control, nephroprotectivity and patients survival³ . To indicate a nephrectomy of the ischemic afunctional kidney with the intention of the treatment of the refractory arterial hypertension is even more challenging. The predictive or indicative value of the plasmatic renin activity and sampling is not unequivocally supported in the literature^4,5. Despite, i tis a consensus, that the correctly choosen patient can benefit from the above mentioned diagnostic as well as from the surgical therapy – nephrectomy⁶.

Conclusion

Laparoscopic nephrectomy is in generally considered low risk procedure. In contrary, many patients with renal artery stenosis are in high or very high risk due to polyvascular atherosclerotic disease, uncontrolled arterial hypertension, diabetes mellitus, chronic heart failure or atrial fibrillation. Thus, the selection of the patient who can profit from nephrectomy of the afunctional kidney is uneasy and should be considered interdisciplinary with the cooperation of the nephrologist, interventional vascular specialist, internist and/or cardiologist. In or casem the follow up of the patient, the reduction of the medication and well controlled blood pressure we consider to be a sufficient proof of the accuracy of the used diagnostic and therapeutic approach.

Literature

1. Alhadad A, Mattiasson I, Ivancev K, Lindblad B, Gottsäter A. Predictors of long-term beneficial effects on blood pressure after percutaneous transluminal renal angioplasty in atherosclerotic renal artery stenosis. Int Angiol. 2009 Apr;28(2):106-12. PMID: 19367240.
2. Rodríguez Jornet A, Ibeas J, Ribera L, Real J, Perendreu J, Falcó J, Vallespín J, Allegué N, Giménez Gaibar A, García García M. Nefropatía isquémica: revascularización o tratamiento médico conservador? [Ischemic renal disease: revascularization or conservative treatment?]. Nefrologia. 2005;25(3):258-68. Spanish. PMID: 16053007.
3. Patel SM, Li J, Parikh SA. Renal Artery Stenosis: Optimal Therapy and Indications for Revascularization. Curr Cardiol Rep. 2015 Sep;17(9):623. doi: 10.1007/s11886-015-0623-7. PMID: 26238738.
4. Strong CG, Hunt JC, Sheps SG, Tucker RM, Bernatz PE. Renal venous renin activity. Enhancement of sensitivity of lateralization by sodium depletion. Am J Cardiol 1971; 27: 602–11.
5. Hasbak P, Jensen LT, Ibsen H. Hypertension and renovascular disease: follow-up on 100 renal vein renin samplings. J Hum Hypertens 2002; 16: 275–80.
6. Baez-Trinidad LG, Lendvay TS, Broecker BH, Smith EA, Warshaw BL, Hymes L et al. Efficacy of nephrectomy for the treatment of nephrogenic hypertension in a pediatric population. J Urol 2003; 170: 1655–7