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Kidney Week

Abstract: FR-PO568

It Is Never Too Late: A Case of Renal Artery Angioplasty for Resistant Hypertension in ESRD

Session Information

Category: Trainee Case Report

  • 703 Dialysis: Peritoneal Dialysis

Authors

  • Tamvada, Dheera, Saint Vincent Hospital, Worcester, Massachusetts, United States
  • Martin, Suzanne G., Saint Vincent Hospital, Worcester, Massachusetts, United States
Introduction

Atherosclerotic renovascular disease is an important and potentially treatable cause of secondary hypertension. In patients with end-stage renal disease, common contributors to uncontrolled hypertension include volume overload, sympathetic overactivity, and erythropoietin-stimulating agents. It is therefore challenging to identify ESRD patients who could benefit from angioplasty for renal artery stenosis.

Case Description

A 65 year old patient with ESRD due to BK nephropathy on peritoneal dialysis developed uncontrolled hypertension requiring multiple medications, including hydralazine 50 mg qAM and 100 mg qPM, isosorbide mononitrate 30 mg qAM and 60 mg qPM, labetalol 200 mg BID, amlodipine 10 mg daily, valsartan 160 mg BID, torsemide 40 mg BID, and doxazosin 8 mg BID. He also had extensive atherosclerosis of the aorta, bilateral common iliac and external iliac arteries requiring multiple stents. He developed resistant hypertension on PD, which was uncontrolled on the above regimen and required several hospitalizations with BP in the 200s/100s. Workup revealed a 99% stenosis of the proximal left renal artery, which was stented. After angioplasty, he had improvement in his blood pressures to 120-130/60-80 on valsartan 160 mg BID and metoprolol succinate 100 mg daily. His 24 hour urine collections for creatinine clearance confirmed increase in urine output, with a urine volume of 508 cc on the final collection pre-angioplasty and 2000 cc on the first collection post-angioplasty. In addition, his weekly Kt/V from residual renal function alone increased from 0.54 before angioplasty to 2.7 after angioplasty. He developed volume overload with a trial off PD which could not be managed with diuretics alone. PD was resumed, with a reduced frequency of four sessions per week.

Discussion

Our patient demonstrated significant improvement in blood pressure control, with a substantial reduction in the number of medications and the stabilization of his blood pressure after angioplasty for renal artery stenosis despite being dialysis-dependent. Residual renal function improved, with fewer PD sessions required weekly to maintain adequate clearance and euvolemia. Particularly in patients with other manifestations of peripheral vascular disease, the possibility of renal artery stenosis should be investigated, and perhaps treated, in ESRD patients with resistant hypertension.