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Abstract: TH-PO163

A Case of Childhood Bilateral Renal Artery Stenosis Not Seen on Angiography

Session Information

Category: Trainee Case Report

  • 1700 Pediatric Nephrology

Authors

  • Rawson, Ashley E., Indiana University School of Medicine, Indianapolis, Indiana, United States
  • Spiwak, Elizabeth, Indiana University- Riley Hospital for Children, Indianapolis, Indiana, United States
  • Schwaderer, Andrew L., Indiana University, Zionsville, Indiana, United States
  • Hains, David S., Indiana University School of Medicine, Indianapolis, Indiana, United States
Introduction

Renovascular hypertension (HTN) is an important cause of secondary HTN in children. Multiple imaging modalities are considered for detection of renal artery stenosis (RAS) such as: duplex ultrasound, CTA, and MRA. However, the gold standard for detection is conventional angiography. We present a case of bilateral RAS that was undetected by angiography.

Case Description

A 12 year old previously healthy female presented to a well-child exam with a BP 180/111 mmHg. Her BMP was remarkable for a serum K+ of 3.2 mmol/L and normal eGFR. Renal US was unremarkable and UA demonstrated microscopic hematuria (5-10 RBCs/hpf). She also had left ventricular hypertrophy on echocardiogram. Hypertension work up included: plasma aldosterone, serum free metanephrines, ACTH, monogenic HTN panel, and serum cortisol levels. Work up was negative other than an elevated aldosterone. A CTA demonstrated "string of beads appearance of the bilateral renal arteries and lobar segments suggestive of bilateral fibromuscular dysplasia and focal moderate-severe stenosis of the proximal left renal artery." Angiography did not demonstrate RAS. She was started on captopril and elevation in creatinine was noted. She was then sent to a vascular surgeon for a second opinion. At that time, angiography was repeated and bilateral renal vein renin measurements were elevated. Via imaging, she had ostial left RAS and mid-right RAS. She is currently managed on clonidine, HCTZ, and lisinopril. She is scheduled for bilateral renal revascularization.

Discussion

This case illustrates the importance of multiple imaging modalities in the work up of renovascular HTN. Our patient underwent angiography by a skilled radiologist and bilateral RAS was not detected, thus we highlight the value of specialized vascular surgery centers for cases with a high index of suspicion.

Angiography showing pt's bilateral RAS.