G HARLEY1, M MATHEW1, R RAJ1
1Launceston General Hospital, Launceston, Tasmania
Background: Atherosclerotic renal artery stenosis represents a common clinical problem with the literature suggesting angioplasty and stenting, usually of bilateral disease, is clinically beneficial only in certain clinic scenarios including refractory hypertension, acute episodes of pulmonary oedema or rapidly declining kidney function clearly attributable to this.
Case report: A 57 year old lady, current smoker on long-term olmesartan for hypertension, presented with a three month history of right flank pain and vomiting associated with an acute creatinine rise to 550micromol/L with proteinuria and quickly progressed to anuric renal failure requiring haemodialysis. A non-contrast CT scan showed 8.9cm and 6.8cm on the right and left respectively without evidence of obstruction. She had persistent refractory hypertension with several episodes of acute hypertension and hypoxia requiring non-invasive respiratory support. A right-sided kidney biopsy showed 3 out of 22 sclerosed glomeruli, some ischaemic glomeruli and evolving widespread tubular atrophy.
A CT renal angiogram showed complete occlusion of bilateral renal artery origins with collateral perfusion of both kidneys. An angioplasty and stenting was successfully performed on day 35 of her admission of her right renal artery. The patient became polyuric quickly and her anti-hypertensives were successfully weaned. Her creatinine over the subsequent weeks reduced to 170micromol/L. Unfortunately she developed hypertension with worsening renal function and was commenced back on haemodialysis approximately 10 weeks after having ceased. A repeat angiogram showed a widely patent right renal artery stent.
Conclusions: Although stenting was initially successful in improving her anuric acute kidney injury, with no further acute pulmonary oedema, ultimately she progressed to dialysis-dependence.