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The purpose of the study is a rigorous validation of different ultrasonic criteria of renal artery stenosis, and the presentation of the performances of duplex sonography in renal artery stenosis screening. Sixty seven patients have been investigated by ultrasonic techniques, and the results of duplex compared with intraarterial or intravenous digital subtraction angiography. Two kinds of ultrasonic investigations have been defined: complete explorations when the renal artery ostium is accessible, incomplete explorations in other cases. The main difficulty preventing the exploration from being complete is obesity: all patient with an overweight of more than 20% of their theoretical weight have an incomplete exploration of at least one of their renal arteries. Furthermore, duplex sonography was not able to demonstrate polar artery in any case. When the exploration is complete, maximum systolic frequency (F max) recorded on the renal artery course, and the systolic frequency ratio of renal and aortic recordings (RAR) are two valuable criteria of significant stenosis (> 50%): mean difference between normal and stenosed arteries for these two variables is statistically significant (p < 0.01). To obtain a good specificity, pathological threshold have been fixed at F max > 3,500 Hz and RRA > 2.5. When the exploration in incomplete, ascending time (asc. T) and resistance index (RI) of doppler recording obtained in the renal hilum are two valuable criteria for severe stenosis (> 80%), or occlusion: the mean between stenosed and non stenosed arteries is statistically different (p < 0.001 and p < 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:[Value and role of echo-Doppler in the screening of renovascular hypertension. A prospective study of 144 arteries with reference to angiography]. 812 34

Duplex-scan is widely used for arterial stenosis diagnosis. Its role in detection of renal artery stenosis remains controversial (2, 17, 19, 28). The aim of this study was to determine retrospectively if duplex-scan is accurate for diagnosis of renal artery stenosis. During 36 months, 764 patients had a renal artery examination with duplex-scan: 90 patients had also renal arteriography. Duplex-scan was feasible in 95% of cases (excess bowel gas or major obesity gave to duplex-scan incomplete results in four patients upon 90). Ninety-three per cent of patients had hypertension; 20% had renal failure; 61% had obstruction of coronary, carotid artery or lower limb arteries. Nineteen patients among 86 had also an intravenous renal arteriography. We compared duplex-scan with venous angiography and intra-arterial arteriography. Duplex-scan criteria for stenoses were: a maximal systolic velocity (MSV) above 180 cm/s for detection of 60% to 79% stenoses and a MSV superior to 300 cm/s for detection of 80% to 99% stenoses. Global results showed a good sensitivity 59/64 (92%) and specificity 112/117 (96%) for duplex-scan. Duplex-scan is accurate for diagnosis of renal artery stenosis in a selected population.
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PMID:[Echo-Doppler and stenosis of the renal arteries. Report of 86 cases]. 875 84

The Jackson Heart Study will be an epidemiological study of African Americans in Jackson, Mississippi, to identify risk factors for development and progression of cardiovascular disease. One of the potential risk factors to be assessed in this study is renal vascular disease. Atherosclerotic renal vascular disease is a disease of the elderly, is predominantly seen in white people, and is strongly associated with diffuse atherosclerotic disease and high-grade hypertensive retinopathy. Patients with ischemic nephropathy may constitute up to 16% of new dialysis patients and die more quickly while on renal replacement therapy. Although often not present, hypertension is a commonly observed consequence (but probably not a cause) of renal vascular disease, and the control of blood pressure may not halt the progression of the disease. Approximately 20-25% of patients with moderate to severe renal artery stenosis will be diabetic. Diabetic patients fair less well with intervention and have a higher progression to end-stage renal disease or death. Obesity is not commonly seen in patients with renal vascular disease. The Jackson Heart Study may be able to assess the true incidence of atherosclerotic renal vascular disease in African Americans and its impact of cardiovascular morbidity and mortality.
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PMID:The role of hypertension, obesity, and diabetes in causing renal vascular disease. 1010 Jun 92

Hypertension as well as hypotension can be harmful to a newly transplanted renal allograft. Elevated blood pressure is also a major risk factor for cardiovascular death, which is a frequent occurrence despite successful renal transplantation. Renal artery stenosis, immunosuppressive drugs, chronic rejection, retained native kidneys, and excessive extracellular fluid volume may all contribute to post-transplant hypertension. Antihypertensive agents are widely used in the management of post-transplant hypertension. Careful clinical judgement and knowledge of the pharmacology, pharmacodynamics, pharmacokinetics, adverse drug reaction profiles, potential contraindications, and drug-drug interactions of antihypertensive agents are important when therapy with antihypertensive drugs is initiated in renal transplant recipients. Since blood pressure elevation in any individual is determined by a large number of hormonal and neuronal systems, the effect of antihypertensive agents on the allograft should be considered a critical factor in the management of hypertension in renal transplant recipients. Most renal transplant recipients have other risk factors for premature cardiovascular death such as diabetes mellitus, hypercholesterolemia, insulin resistance, obesity, left ventricular hypertrophy and ischaemic heart disease. Initial antihypertensive therapy should be tailored individually according to the patient's risk factors. A realistic therapeutic goal for blood pressure management in the initial post-operative state is a systolic blood pressure <160 mm Hg and a diastolic blood pressure <90 mm Hg with lower pressure targets becoming applicable late post-transplantation.
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PMID:A practical guide to the management of hypertension in renal transplant recipients. 1065 88

Renal artery stenosis may be a cause of hypertension and a potential contributor to progressive renal insufficiency. However, the prevalence of renal artery disease in a general population is poorly defined. The purposes of this study were to evaluate the prevalence of angiographically-determined renal artery narrowing in a patient population undergoing routine cardiac catheterization, and to identify the risk factors for renal artery stenosis. After left ventriculography, abdominal aortography was performed to screen for the presence of renal artery stenosis. A total of 427 patients (274 males, 153 females) were studied and the mean age was 59 years. Renal artery narrowing was identified in 10.5% of patients. Significant (> or = 50% diameter narrowing) renal artery stenosis was found in 24 patients (5.6%) and insignificant stenosis was found in 21 patients (4.9%). Significant unilateral stenosis was present in 4.2% of patients and bilateral stenosis was present in 1.4%. The stem of the renal artery was a more common site of stenosis in 62.2% of patients than in the ostium (37.8%), but the severity of stenosis was not significantly different according to the site of stenosis. By univariate and multivariate logistic regression analysis, the association of clinical variables with renal artery stenosis was assessed. Multivariable predictors included age, hypertension and peripheral vascular disease (p < 0.05). The variables such as sex, smoking history, hyperlipidemia, renal insufficiency, as well as the presence of obesity, severity of coronary heart disease and D.M., were not associated. In conclusion, the prevalence of angiographically-determined renal artery narrowing in a patient population undergoing cardiac catheterization is 10.5%. Old age, hypertension and evidence of peripheral vascular disease represent the predictors of renal artery stenosis.
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PMID:The prevalence and associated risk factors of renal artery stenosis in patients undergoing cardiac catheterization. 1081 23

Recent clinical trials suggest that resistant hypertension is increasingly common. In the majority of patients, uncontrolled hypertension is due to persistent elevation of the systolic blood pressure. Older age and obesity are associated with poor blood pressure control. Other contributing factors include severity of the underlying hypertension and renal insufficiency. Poor patient adherence is thought be a common cause of medication resistance. Exogenous substances such as nonsteroidal anti-inflammatory drugs, oral contraceptives, and sympathomimetic agents can interfere with treatment. The prevalence of secondary causes of hypertension increases with age, especially atherosclerotic renal artery stenosis. Recent reports suggest that primary aldosteronism may be the most common secondary cause of hypertension. It should be considered in all patients with resistant hypertension. Effective treatment of resistant hypertension requires identification and reversal of contributing factors and/or secondary causes of hypertension. Pharmacologic therapy should utilize combination therapy, including a long-acting diuretic.
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PMID:Resistant hypertension. 1200 5

The purpose of this study was to evaluate the utility of computed tomography (CT) renal angiogram (CTRA) in the management of childhood hypertension. This is a retrospective study of 24 children with clinical suspicion of renovascular disease who underwent CTRA examinations. CTRA demonstrated surgically correctable etiology of hypertension in 38% of the patients [5 with renal artery stenosis (RAS) and 4 with renal pathology]. In 5 patients, CTRA findings of RAS were confirmed by catheter angiogram. CTRA missed RAS in 1 patient in whom catheter angiogram showed beaded narrowing of the renal artery. All 6 patients with RAS had resolution of hypertension immediately after angioplasty or surgery. One patient with diffuse renal artery stenosis had an ipsilateral multicystic dysplastic kidney. In this patient hypertension resolved spontaneously as the dysplastic kidney shrunk in size. Seven patients had a renal etiology for hypertension. In 3 of these patients hypertension resolved after nephrectomy. Malignant hypertension in the 4th patient with reflux nephropathy was controlled medically after she underwent bilateral ureteral reimplantation. The remaining 3 patients with renal etiology were managed medically. We found that the etiology was central for hypertension in 4 patients with brain abnormalities, obesity in 1 overweight patient, essential hypertension in 4 patients, and thoracic aorta coarctation in 1 patient. Our study showed that in all except 1 instance CTRA could diagnose a surgically correctable cause for hypertension. CTRA provided useful information for the management of pediatric hypertension in all our patients.
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PMID:Utility of computed tomographic renal angiogram in the management of childhood hypertension. 1221 28

To evaluate the possible role of the kidney in the enhanced metabolic clearance rate (MCR) of GH in obesity, we studied the kinetics of GH and renal fractional extraction of GH (RFEGH) in 12 male hypertensive patients over a wide range of body weights (71.7-129 kg) while undergoing contrast angiography on suspicion of renal artery stenosis. A continuous infusion of recombinant human GH was administered during a continuous infusion of somatostatin to suppress endogenous GH secretion. After 2 h of GH infusion, when plasma GH had reached a steady state at concentrations that were still in the physiological range, blood was sampled from the left and right renal arteries and veins for determination of GH levels. Subsequently, the GH infusion was stopped, and GH kinetics were investigated with noncompartmental analysis. In none of the patients was hemodynamically significant renal artery stenosis present. Whole body MCR of GH averaged 375 +/- 142 ml/min. Average GH levels were significantly higher in arterial plasma than in simultaneously sampled renal venous plasma (P < 0.001). RFEGH was 8.6 +/- 6.8%. The MCRs of both GH and RFEGH correlated significantly with body weight, body fat mass, and endogenous creatinine clearance. Renal uptake of GH per 100 g kidney tissue correlated inversely with MCR. These results suggest that RFEGH rises with increasing adiposity, but per unit of renal mass, the capacity of the kidney to remove GH from the circulation falls at high MCR values.
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PMID:Renal contribution to increased clearance of exogenous growth hormone in obese hypertensive patients. 1557 27

The relationship of hypertensives and many pathological syndromes still remains unclear. A mathematical model in terms of the fluid mechanics and physicochemical analyses is established to correlate the plasma viscosity, the shear stress and the rate of shear in blood stream with the ligand-receptor dissociation constant. This model has arrived at the conclusive results that high viscosity, high rate of shear created in the blood streams, and the peripheral resistance may act as important preceding factors to induce a serial subsequent pathological clinical manifestations. High viscosity may interfere with the ligand-receptor combination, in contrast, high rate of shear may knock the ligand (s) off the existing ligand-receptor complex, while elevation of peripheral resistance may slow down the blood flow rate, resulting in a diminished dissociation of ligand-receptor complex. This model has successfully interpreted the possible cause of some post-hypertensive abnormal outcome manifestations involving obstructive and degenerative stenosis (such as renal artery stenosis), growth retardation, blood vessel detriment, coarctation of aorta, coronary thrombotics, atherosclerosis, hyperinsulinemia, diabetes, obesity, hypothyroidism, infertility, and at the worst, carcinoma, etc.
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PMID:Fluid mechanical and physicochemical modeling interprets hypertension to be capable of inducing secondary complications. 1714 24

Identification and treatment of hypertension should be an important focus of physicians caring for children. Ultimately, a link between hypertension in children and the risk of cardiovascular disease will be established. Further long-term studies are likely to show that morbidity and mortality will be decreased by the institution of treatment of hypertension in children. Additional risk factors such as obesity and lipid disorders should be sought and targeted for treatment as well. Lifestyle modifications are advised for all patients and can be tried solely for those with blood pressures between the 95th and 99th percentiles. Drug therapy is indicated in children with blood pressures greater than the 99th percentile, secondary hypertension, coexisting diabetes, left ventricular hypertrophy, or those who fail a trial of nonpharmacologic treatment. Children with white coat hypertension should not be treated with drugs. Children with renal artery stenosis and drug-refractory hypertension should be considered for percutaneous angioplasty or surgery depending on the anatomy of the lesion and operator experience. Children requiring multiple drug classes for control of blood pressure and older adolescents on one drug with renal artery lesions amenable to a percutaneous procedure may elect intervention in an attempt to reduce or eliminate drug therapy. Infants and children with hypertension due to native coarctation of the aorta should undergo surgical repair. Older children and adolescents with native coarctation should have surgical repair or percutaneous angioplasty/stenting. Hypertension secondary to recurrent coarctation is usually treated with a percutaneous intervention.
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PMID:Management of systemic hypertension in children and adolescents: an update. 1789 67


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