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Abstract: PO2099

Bilateral Nephrectomy in a Patient with Refractory Hypertension Prior to Development of ESKD

Session Information

Category: Trainee Case Report

  • 1402 Hypertension and CVD: Clinical, Outcomes, and Trials

Authors

  • Zemke, Anna M., Department of Medicine, Rush University Medical Center, Chicago, Illinois, United States
  • Hlepas, Alexander, Department of Medicine, Rush University Medical Center, Chicago, Illinois, United States
  • Hertl, Martin, Department Transplant Surgery, Rush University Medical Center, Chicago, Illinois, United States
  • Ali, Waleed, Department of Medicine, Comprehensive Hypertension Center, University of Chicago Medicine, Chicago, Illinois, United States
  • Rodby, Roger A., Department of Medicine, Division of Nephrology, Rush University Medical Center, Chicago, Illinois, United States
  • Bakris, George L., Department of Medicine, Comprehensive Hypertension Center, University of Chicago Medicine, Chicago, Illinois, United States
Introduction

Renal denervation (RDN) reduces increased sympathetic activation in refractory HTN (rHTN) while preserving kidney function, and trials in both the US and Europe demonstrate a 7-12 mmHg placebo subtracted reduction in systolic BP. Bilateral nephrectomy (BLN), originally performed in ESKD patients in the 1970s for rHTN is an effective treatment, but is reserved for ESKD pts. We present a case of life threatening rHTN in a pt with Stage 3b CKD that was unresponsive to open surgical renal denervation (OS RDN) but responded extremely well to BLN.

Case Description

A 43 y/o white woman with stage 3b CKD (eGFR 38 ml/min/1.73m2) presented with a resting SBP between 180-240 mmHg on maximal doses of 8 different antihypertensive medications including spironolactone and minoxidil. She required frequent hospitalizations for symptomatic HTN with IV CCBs and beta blockers. Workup included an evaluation of all secondary causes including drug screening, urine metanephrines, renal MRI, and renin/aldo ratio.

In an effort to avoid BLN, she initially underwent bilateral OS RDN by severing all neural tissue entering the kidney. Renal vein renin levels were 9.1, 7.8 ng/mL/hr pre OS RDN and 0.7, 1.4 ng/mL/hr post. Despite an initial drop in BP to 140/70 mmHg on only 2 medications, within 4 wks of OS RDN, her BP rose to 240/120 on 4 medications and she was symptomatic. At this point, BLN was performed as the only remaining option. Understanding of the need for RRT following BLN, the patient consented to proceed. Follow up BPs have been in the 130/80 mmHg range on carvedilol dose 12.5mg bid alone.

Discussion

Neither OS RDN nor pre-ESKD BLN for rHTN have been previously reported. Advancements in endovascular RDN are becoming more effective, but still only lower systolic BP by 7-12 mmHg placebo subtracted. Our case failed to respond to OS RDN, where we were guaranteed completed resection of the nerves and surrounding connective tissue, and suggests the effects of any form of RDN may be limited. BLN for rHTN for pts on RRT was started in the 1970s. Almost 50 yrs later, despite enormous improvements in medications, there is still a role for this procedure, and it emphasizes how little we still know about the etiology of rHTN. Requiring this in a patient pre-ESKD was extreme but we felt a life-saving requirement. She will be referred for transplantation.