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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 35  |  Issue : 2  |  Page : 83-85

Successful treatment of bilateral renal artery stenosis in a patient presenting with acute kidney injury


1 Department of Nephrology, Shija Hospitals and Research Institute, Imphal, Manipur, India
2 Department of Interventional Radiology, Shija Hospitals and Research Institute, Imphal, Manipur, India
3 Department of Cardiology, Shija Hospitals and Research Institute, Imphal, Manipur, India

Date of Submission23-May-2021
Date of Acceptance21-Aug-2021
Date of Web Publication27-Nov-2021

Correspondence Address:
Guliver Potsangbam
Kwakeithel Moirang Purel Leikai, Imphal West - 795 001, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_69_21

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  Abstract 


A common causes of secondary hypertension is renal artery stenosis (RAS), of which the vast majority are caused by atherosclerosis. Since angiotensin II receptor blockers (ARBs) are one of the most commonly used antihypertensives, their use may precipitate acute kidney injury in patients who have an underlying bilateral renal artery stenosis. In this case report, a female patient with bilateral severe ostial stenosis of the renal arteries developed acute kidney injury (AKI) requiring renal replacement therapy. Post angioplasty and stenting of the bilateral renal arteries, the patient made a complete renal recovery.

Keywords: Angioplasty, bilateral, renal artery stenosis, telmisartan


How to cite this article:
Potsangbam G, Thangjam G, Kumar Sharma GS, Rajkumari N, Laishram S. Successful treatment of bilateral renal artery stenosis in a patient presenting with acute kidney injury. J Med Soc 2021;35:83-5

How to cite this URL:
Potsangbam G, Thangjam G, Kumar Sharma GS, Rajkumari N, Laishram S. Successful treatment of bilateral renal artery stenosis in a patient presenting with acute kidney injury. J Med Soc [serial online] 2021 [cited 2022 Aug 15];35:83-5. Available from: https://www.jmedsoc.org/text.asp?2021/35/2/83/331345




  Background Top


Renal artery stenosis (RAS) is a common cause of secondary hypertension.[1] The majority are caused by atherosclerosis. Angiotensin II receptor blockers (ARBs) are one of the most commonly used antihypertensives. We present a female patient with bilateral severe ostial stenosis of the renal arteries who developed acute kidney injury (AKI) requiring renal replacement therapy.


  Case Presentation Top


A 63-year-old female presented with complaints of shortness of breath on exertion and lying down, chest pain on exertion, and intermittent leg swelling for the past 15 days. She had arterial hypertension for the past 20 years and was currently on tablet cilnidipine 10 mg/day. She was also hypothyroid on 50 μg of levothyroxine (T4) daily. Her blood pressure was 150/90 mmHg with no difference between the two arms. She was a nondiabetic with no history of substance abuse. Laboratory tests results were as follows, blood urea 54.92 mg/dl, serum creatinine 1.09 mg/dl, sodium 147 mEq/l, potassium 4.42 mEq/l, and chloride 100.5 mEq/l. Her estimated glomerular filtration rate (eGFR) was calculated to be 54 ml/min/1.73 m2. In view of her electrocardiogram findings suggestive of ischemic heart disease and echocardiographic findings which demonstrated an ejection fraction of 50% along with dilated left atrium, cilnidipine was stopped and she was started on telmisartan 40 mg. A plan was formulated to perform a coronary angiography once the patient was stabilized.

She was referred to the nephrology department for a rapid deterioration of her kidney function. Her eGFR declined from 54 ml/min/1.73 m2 to 10 ml/min/1.73 m2 over 7 days. She also developed worsening appetite and nausea and was subsequently admitted for evaluation of her worsening renal functions. Telmisartan was stopped, and she was started on clonidine 100 μg Q8Hr to control her blood pressure.

Further evaluation with ultrasonography showed normal kidneys along with cholelithiasis. Doppler ultrasonography of the renal arteries showed narrowing of the right renal artery at the origin with an increased peak systolic velocity (PSV) of 215 cm/s. PSV of the right intrarenal segment was 20 cm/s (decreased). Tardus parvus waveform was present. RI was 0.6, and there was no diastolic reversal of blood flow. The left renal artery showed a similar finding with narrowing of the origin of the left renal artery.

Her renal functions continued to deteriorate, and hemodialysis was instituted in view of worsening metabolic acidosis and uremic symptoms.

Angiogram of the right renal artery revealed severe (90%) stenosis of the proximal region [Figure 1]a. There was 90% stenosis of the left main renal artery with thrombus (acute-on-chronic RAS) [Figure 1b]. The thrombus was aspirated, which revealed an underlying chronic stenosis. Subsequently, angioplasty was performed and a stent was inserted in the left renal artery. Angioplasty and stenting were also successfully done in the right renal artery [Figure 1]c & [Figure 1]d. There was rapid improvement in her renal functions, and she was discharged with a nadir serum creatinine of 3.8 mg/dl. It further declined to 1.21 mg/dl at post procedure day 40.
Figure 1: Renalarteryangiography.(a)Criticalrightrenalarteryostialstenosis,(b)leftrenalarteryfillingdefectcausingabruptocclusionrepresentingintraluminalthrombus,(c)postaspirationshowingunderlyingchronicstenosis,(d)postangioplastyandstentinsertion,bloodflowtobothrenalarterieswasmarkedlyimproved

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  Discussion Top


RAS is an important cause of hypertension and kidney dysfunction that commonly occurs as a result of atherosclerosis of the renal arteries.[1] Consequently, blood flow to the kidney is reduced and the renin–angiotensin–aldosterone system (RAAS) is activated in an attempt to maintain renal blood flow. Angiotensin II maintains the efferent arteriolar tone keeping the pressure relatively constant in the glomerulus and thus keeps the GFR stable over a wide variety of perfusion pressures. In patients who are susceptible to decreased renal blood flow, i.e., patients with bilateral RAS, renal impairment, severe congestive heart failure, and severe sodium and volume depletion, loss of this response due to angiotensin-converting enzyme inhibitors or ARB can result in AKI, because their renal function is often angiotensin dependent.

ARBs are an important group of antihypertensives. Inhibition of the RAAS constitutes an important part of the treatment of cardiac disease since they limit cardiac hypertrophy and fibrosis, and reduces ventricular wall stress.[2] Unfortunately, these patients often have associated atherosclerotic and RAAS inhibition may cause an adverse outcome when an underlying RAS is present. Thus, careful monitoring of kidney function is required, especially in patients of bilateral RAS.[3] ARBs have been known to cause rapidly progressive renal insufficiency in patients with preexisting bilateral RAS.[4]

This patient in our report developed rapidly progressive renal insufficiency after she was started on telmisartan because of the presence of bilateral RAS and an acute thrombus at the origin of the left renal artery.

In situ thrombosis of the renal artery, though uncommon, is most commonly associated with blunt abdominal trauma[5] and atherosclerotic lesions of the artery.[6] Other less common causes are polycythemia vera, hypercoagulability, nephrotic syndrome, pregnancy, renovascular hypertension, and renal angiography, though spontaneous renal artery thrombosis without a known cause is unlikely to occur.

Aspiration of the left renal artery thrombus was performed, followed by angioplasty and stenting of the underlying chronic stenosis. Similarly, angioplasty and stenting of the right renal artery was performed. Subsequently, kidney functions improved remarkably.

We feel that this case serves as a reminder to be vigilant when starting RAAS blockade in the elderly patient. Furthermore, appropriate and timely intervention can lead to a gratifying outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Manaktala R, Tafur-Soto JD, White CJ. Renal artery stenosis in the patient with hypertension: Prevalence, impact and management. Integr Blood Press Control 2020;13:71-82.  Back to cited text no. 1
    
2.
Main J. Atherosclerotic renal artery stenosis, ACE inhibitors, and avoiding cardiovascular death. Heart 2005;91:548-52.  Back to cited text no. 2
    
3.
Volpe M, Savoia C, De Paolis P, Ostrowska B, Tarasi D, Rubattu SS. The renin-angiotensin system as a risk factor and therapeutic target for cardiovascular and renal disease. JASN 2002;13 Suppl 3:S173-8.  Back to cited text no. 3
    
4.
Bavbek N, Kasapoglu B, Isik A, Kargili A, Kirbas I, Akcay A. Olmesartan associated with acute renal failure in a patient with bilateral renal artery stenosis. Ren Fail 2010;32:1115-7.  Back to cited text no. 4
    
5.
Cosby RL, Miller PD, Schrier RW. Traumatic renal artery thrombosis. Am J Med 1986;81:890-4.  Back to cited text no. 5
    
6.
Singh S, Wang L, Yao QS, Jyotimallika J, Singh S. Spontaneous renal artery thrombosis: An unusual cause of acute abdomen. N Am J Med Sci 2014;6:234-6.  Back to cited text no. 6
    


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