A 20 year old female presents with a blood pressure of 160/110 mm Hg. Clinical examination reveals a bruit in both flanks. Which of the following statements about this patient is not true (select one option)
Correct Answer: Condition is nearly always bilateral
Description: Answer is C (Condition is nearly always bilateral): Presence of hypeension (BP = 160 / 110) and bruit in bilateral flanks suggest a diagnosis of Bilateral Renal Aery Stenosis in this patient. Rena! Aery Stenosis is bilateral in 50% of cases and is not nearly always bilateral ACE inhibitors (eg Enalapril) may deteriorate renal function in patients with Bilateral Renal Aery Stenosis ACE inhibitors (eg Enalapril) are the agents of choice for treatment of hypeension in patients with unilateral renal aery stenosis, but are contraindicated in patients with bilateral disease. The presence of bruit in both flanks suggest bilateral disease in this patient and hence enalapril should not be used Contrast Enhanced Aeriography (Angiography) is the most definitive diagnostic procedure for the diagnosis of Renal Aery stenosis while Magnetic Resonance Angiography (MRA) is the most sensitive and specific non invasive test (screening test) for its diagnosis. Fibromuscular dysplasia is the most common cause of Renal Aery stenosis in young women while Atherosclerotic disease is the most common cause in middle aged/ elderly patients. The patient in question is a young female (20 years) and hence the most likely cause of Renal Aery stenosis in this patient is fibromuscular dysplasia Surgical Intervention may be required in patients with Bilateral Renal Aery Stenosis Surgical intervention in the form of angioplasty and stent placement is indicated when medical therapy has failed to control BP or resulted in > 30% increase in serum creatinine. Renal Aery Stenosis: Review Renal Aery stenosis is an impoant cause of Renovascular Hypeension Bilateral involvement is seen in half of the affected cases (50%) Etiology Atherosclerotic disease : This is the most common cause in middle aged /elderly patients Fibromuscular Dysplasia : This is the most impoant cause in young females Presentation Hypeension - Abrupt onset of hypeension - Acceleration of previously well controlled hypeension - Refractory Hypeension Features of increased sympathetic neural activity (which is associated with Renovascular disease) - Flushing - Loss of nocturnal BP decrease - Putonomic instability - Rapid BP swings Progressive Renal failure / Azotemia Diagnosis Magnetic Resonance Angiography (MRA) MRA is the most sensitive (>90%) and specific (95%) non invasive test for the diagnosis of RAS Contrast Enhanced Aeriography Contrast enhanced angiography is the most definitive (but invasive) diagnostic procedure for diagnosis of RAS Management Medical Therapy with ACE Inhibitors or Angiotensin Receptor Blockers Indications Unilateral Renal aery Stenosis - With hypeension & normal renal function (more effective than other antihypeensives) - With hypeension & abnormal renal function (beneficial effect on survival without affecting renal function) - With hypeension, diabetes, proteinuria and normal or abnormal renal function (effective antihypeensives) Contra indications Bilateral Renal Aery stenosis ACE inhibitors or Angiotensin receptor blockers are contraindicated in patients with Bilateral renal aery stenosis or stenosis in a solitary kidney as their use in such patients leads to worsening of renal failure (These patients are especially sensitive to decline in intraglomerular pressure) Note Acute Renal Failure / Worsening of Renal Failure with Angiotension Receptor Inhibitors is a diagnostic clue to the diagnosis of renal aery stenosis (indicates bilateral disease) Surgical Therapy with Angioplasty + Stent placement Should be considered only after optimal medical therapy has failed to achieve goal BP or resulted in a > 30% increase in serum creatinine
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