Abstract: TH-PO635

Renovascular Hypertension: A Diagnostic and Therapeutic Conundrum

Session Information

Category: Nephrology Education

  • 1302 Fellows and Residents Case Reports

Authors

  • Koratala, Abhilash, University of Florida, Gainesville, Florida, United States
  • Malpartida, Freddy Rick, University of Florida, Gainesville, Florida, United States
  • Wayangankar, Siddharth, University of Florida , Gainesville, Florida, United States
  • Mohandas, Rajesh, University of Florida, Gainesville, Florida, United States
Background

The commonest causes of renal artery stenosis (RAS) are atherosclerosis and fibromuscular dysplasia (FMD). Despite the availability of advanced imaging modalities, there are substantial challenges to accurately distinguishing between the two. Since treatment options and benefits of revascularization are different in FMD and atherosclerosis, it is essential to make an accurate diagnosis. Herein, we present the case of a young patient with hypertension (HTN) and RAS who was mistakenly labelled as FMD and later diagnosed with atherosclerotic RAS.

Methods

A 46-year-old woman with a diagnosis of FMD was referred to us for evaluation of resistant HTN. Uncontrolled HTN was confirmed by ambulatory blood pressure monitoring. 3 months prior to presentation, she had undergone angioplasty and stenting of the left renal artery for imaging suggestive of FMD. We optimized her anti-hypertensive regimen and recommended life-style modifications. At follow up, her clinic BP was 258/130 mmHg. She was on lisinopril 10mg, amlodipine 10mg, Chlorthalidone 25mg and spironolactone 25mg/ day. Renal angiography confirmed in-stent restenosis (90%) of the left renal artery and 80% diffuse stenosis of the ostial and proximal segments of the right renal artery. Intvascular ultrasound (IVUS) demonstrated atherosclerotic plaques. The proximal and ostial nature of the disease, absence of beading, and presence of plaques in a patient with diabetes and history of irradiation suggested atherosclerotic RAS. The restenosis was successfully treated with IVUS guided angioplasty [Figure]. Her blood pressures improved immediately after the procedure and she was weaned off all antihypertensive medications other than Lisinopril and chlorthalidone.

Conclusion

Accurately distinguishing between FMD and atherosclerotic RAS is critical. FMD is usually treated with angioplasty while most patients with atherosclerotic RAS do not benefit from revascularization. Patients who have stents placed should undergo periodic surveillance for restenosis with Doppler ultrasound.