A controversial renovascular case - The Scottish Renal ...



A controversial renovascular case.

JP Traynor, J Pryce, M Hand and D Kingsmore

A 62-year old female patient with documented history of atheromatous renovasular disease requiring bilateral renal artery stents developed acute renal failure and pulmonary oedema after a 1 week history of nausea, vomiting and mild fever. She was admitted directly to ITU for ventilation and dialysis. Her past medical history included bilateral renal artery stenting performed in 2005, a possible sub-endothelial MI in 2000, hypertension and central obesity. Prior to this admission, her baseline creatinine was 118 umol/L and she was 2 anti-hypertensives although BP control was sub-optimal.

After initial investigations including Doppler ultrasound proved to be either negative or unhelpful, formal renal angiography was performed (18 days after she presented). This revealed a patent right renal artery supplying a small kidney, and an occluded renal artery stent on the left supplying a larger (10.4cm) kidney. The cause of the occlusion was not clear but was felt to be either neo-intimal hyperplasia or in-situ thrombosis. The renal artery lesion was successfully angiolastied and 2 further stents placed within the original stent. She started passing large volumes of urine almost immediately, and other than one dialysis session immediately after the procedure to minimise contrast nephropathy, required no further dialysis. She was started on a statin and warfarin and was able to be discharged shortly after. At follow up 1 month later, her serum creatinine had fallen to 85 umol/L with a BP 120/76 on atenolol only.

In January 2007, she re-presented with acute pulmonary oedema and again required ITU admission and dialysis. This time she had been completely well until 12 hours prior to admission. Further angiography revealed that the left renal artery stents had collapsed although a small amount of contrast filling normal vessels distally. It was felt that this was providing some renal perfusion although not enough to allow adequate clearance of small solutes and free water.. Attempted angioplasty from the groin was unsuccessful on 2 occasions. Her long-term dialysis options were limited. Temporary dialysis access had been extremely difficult to achieve and we were pessimistic about chances of either a tunnelled semi-permanent catheter or AV fistula. Also, due to her central obesity PD was not a realistic option. After 10 days of being dialysis-dependent she was therefore referred for consideration of exploration of the right kidney, and if viable, revascularisation using either ilio-renal bypass or auto-transplantation to the right iliac fossa, with reconstruction of the renal artery with either the internal iliac or long saphenous vein, given that the long-term future on dialysis would be a transplant.

RENAL FUNCTION AND VASCULAR STIFFNESS IN CORONARY ARTERY DISEASE

Christian Delles1 Lukas U. Zimmerli1, Kenneth J. MacArthur2, Tracey Steedman1, Henry J. Dargie1, and Anna F. Dominiczak1

1 BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow

2 Department of Cardiothoracic Surgery, Western Infirmary, Glasgow

Objective. We have previously demonstrated increased vascular stiffness in end-stage renal disease and in coronary artery disease (CAD). Here we examine whether mild to moderate renal impairment further increases vascular stiffness in patients with severe CAD.

Design and method: In 72 patients with severe three-vesel CAD (age, 62±9 years) we measured carotid-femoral pulse wave velocity (PWV; n=52) using the SphygmoCor® Vx system and compliance of the ascending aorta by cardiac MRI (1.5 T Siemens Sonata; n=49). Glomerular filtration rate (eGFR) and creatinine clearance (ClCrea) were estimated by 4-variable MDRD formula and the formula of Cockroft and Gault, respectively.

Results. eGFR ranged from 27 to 103 (mean, 63±14) mL/min and ClCrea from 34 to 129 (mean, 74±23) mL/min. Patients with eGFR ................
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