Takayasu arteritis: differential diagnosis in a teenager with severe acute kidney injury - a case report / Arterite de Takayasu: diagnóstico diferencial em adolescente com lesão renal aguda grave - relato de caso

ABSTRACT Takayasu arteritis (TA) is a chronic granulomatous inflammatory condition of unknown cause that involves large vessels - particularly the aorta and its branches - such as the carotid, coronary, pulmonary, and renal arteries. The left subclavian artery is the most frequently involved vessel. Stenosis of the renal artery has been reported in 23-31% of the cases and may result in malignant hypertension, ischemic renal disease, decompensated heart failure, and premature death. Involvement of both renal arteries is uncommon. Early onset anuria and acute kidney injury are rare and have been reported only in a few cases in the literature. This report describes the case of a 15-year-old female with constitutional symptoms evolving for a year, combined with headache, nausea, and vomiting, in addition to frequent visits to emergency services and insufficient clinical examination. The patient worsened significantly six months after the onset of symptoms and developed acute pulmonary edema, oliguria, acute kidney injury, and difficult-to-control hypertension, at which point she was admitted for intensive care and hemodialysis. Initial ultrasound examination showed she had normal kidneys and stenosis-free renal arteries. The patient was still anuric after 30 days of hospitalization. A biopsy was performed and revealed her kidneys were normal. Computed tomography angiography scans of the abdominal aorta presented evidence of occlusion of both renal arteries. The patient met the diagnostic criteria for Takayasu arteritis and had a severe complication rarely described in the literature: stenosis of the two renal arteries during the acute stage of ischemic renal disease.

RESUMO A Arterite de Takayasu (AT) é uma doença inflamatória crônica, granulomatosa, de causa desconhecida, que afeta grandes vasos, principalmente a aorta e seus ramos, incluindo artérias carótidas, coronárias, pulmonares e renais, sendo a artéria subclávia esquerda o vaso mais acometido. A estenose da artéria renal é relatada em 23-31% dos casos e pode resultar em hipertensão maligna, insuficiência renal por isquemia, descompensação cardíaca e morte prematura. O acometimento bilateral de artérias renais é incomum, sendo rara a presença de anúria súbita e lesão renal aguda como sintoma inicial da doença, com poucos relatos na literatura. O caso reporta uma adolescente de 15 anos com sintomas constitucionais durante um ano de evolução, associados a problemas como cefaleia, náuseas e vômitos, com idas frequentes a serviços de emergência, sem adequada investigação clínica. Após 6 meses do início dos sintomas, a paciente evoluiu de forma grave, com quadro de edema agudo de pulmão, oligúria, lesão renal aguda e hipertensão arterial de difícil controle, sendo necessário suporte em Unidade de Terapia Intensiva e hemodiálise. A ultrassonografia inicial mostrava rins normais e artérias renais sem sinais de estenose. Após 30 dias de internamento, paciente permanecia anúrica, sendo realizada biópsia renal que se mostrou dentro dos padrões da normalidade. Angiotomografia de aorta abdominal evidenciou oclusão bilateral de artérias renais. A paciente descrita fechou critérios diagnósticos para arterite de Takayasu e manifestou uma complicação grave pouco descrita na literatura: estenose bilateral de artérias renais, ainda na fase aguda da nefropatia isquêmica.

Takayasu arteritis: differential diagnosis in a teenager with severe acute kidney injury - a case report.

Takayasu arteritis (TA) is a chronic granulomatous inflammatory condition of unknown cause that involves large vessels - particularly the aorta and its branches - such as the carotid, coronary, pulmonary, and renal arteries. The left subclavian artery is the most frequently involved vessel. Stenosis of the renal artery has been reported in 23-31% of the cases and may result in malignant hypertension, ischemic renal disease, decompensated heart failure, and premature death. Involvement of both renal arteries is uncommon. Early onset anuria and acute kidney injury are rare and have been reported only in a few cases in the literature. This report describes the case of a 15-year-old female with constitutional symptoms evolving for a year, combined with headache, nausea, and vomiting, in addition to frequent visits to emergency services and insufficient clinical examination. The patient worsened significantly six months after the onset of symptoms and developed acute pulmonary edema, oliguria, acute kidney injury, and difficult-to-control hypertension, at which point she was admitted for intensive care and hemodialysis. Initial ultrasound examination showed she had normal kidneys and stenosis-free renal arteries. The patient was still anuric after 30 days of hospitalization. A biopsy was performed and revealed her kidneys were normal. Computed tomography angiography scans of the abdominal aorta presented evidence of occlusion of both renal arteries. The patient met the diagnostic criteria for Takayasu arteritis and had a severe complication rarely described in the literature: stenosis of the two renal arteries during the acute stage of ischemic renal disease.

Estenosis de la arteria renal unilateral de diagnóstico neonatal / Neonatal diagnosis of unilateral renal artery stenosis

La estenosis de la arteria renal es una causa rara de hipertensión arterial neonatal de origen renovascular. Hay muy pocos casos descritos en la literatura en esta etapa. La mayor parte de los pacientes con esta afectación permanecen asintomáticos, y la hipertensión se detecta en las revisiones pediátricas rutinarias. El diagnóstico puede realizarse mediante la combinación de hallazgos bioquímicos y radiológicos. El manejo inicial del paciente se basa en terapia farmacológica hasta alcanzar un crecimiento adecuado para evaluar la reparación definitiva de la lesión vascular o la nefrectomía en caso de supresión funcional del riñón afecto. Se presenta a una paciente femenina recién nacida a término, con hipertensión arterial e importante falla cardíaca congestiva, originada por una estenosis unilateral de la arteria renal, con supresión funcional y atrofia del riñón afecto, que precisó importante soporte inotrópico y antihipertensivo durante los primeros días de vida, con importante mejoría clínica posterior.

Renal artery stenosis represents a rare cause of neonatal arterial hypertension of renovascular origin, having been described few cases in the literature at this stage of life. Most patients with this disease remain asymptomatic; hypertension can be detected in routine pediatric revisions. Diagnosis can be performed by combining biochemical and radiological findings. The initial management consists of pharmacological therapy in order to achieve adequate growth. Subsequently, it is necessary to assess definitive repair of the vascular lesion or nephrectomy in the case of functional abolition of the affected kidney. We present a term newborn female, with arterial hypertension and an important congestive heart failure, caused by a unilateral renal artery stenosis, with functional abolition and atrophy of the affected kidney, which required an important inotropic and antihypertensive support during her first days of life, with significant clinical improvement subsequently.

[Neonatal diagnosis of unilateral renal artery stenosis]. / Estenosis de la arteria renal unilateral de diagnóstico neonatal.

Renal artery stenosis represents a rare cause of neonatal arterial hypertension of renovascular origin, having been described few cases in the literature at this stage of life. Most patients with this disease remain asymptomatic; hypertension can be detected in routine pediatric revisions. Diagnosis can be performed by combining biochemical and radiological findings. The initial management consists of pharmacological therapy in order to achieve adequate growth. Subsequently, it is necessary to assess definitive repair of the vascular lesion or nephrectomy in the case of functional abolition of the affected kidney. We present a term newborn female, with arterial hypertension and an important congestive heart failure, caused by a unilateral renal artery stenosis, with functional abolition and atrophy of the affected kidney, which required an important inotropic and antihypertensive support during her first days of life, with significant clinical improvement subsequently.

La estenosis de la arteria renal es una causa rara de hipertensión arterial neonatal de origen renovascular. Hay muy pocos casos descritos en la literatura en esta etapa. La mayor parte de los pacientes con esta afectación permanecen asintomáticos, y la hipertensión se detecta en las revisiones pediátricas rutinarias. El diagnóstico puede realizarse mediante la combinación de hallazgos bioquímicos y radiológicos. El manejo inicial del paciente se basa en terapia farmacológica hasta alcanzar un crecimiento adecuado para evaluar la reparación definitiva de la lesión vascular o la nefrectomía en caso de supresión funcional del riñón afecto. Se presenta a una paciente femenina recién nacida a término, con hipertensión arterial e importante falla cardíaca congestiva, originada por una estenosis unilateral de la arteria renal, con supresión funcional y atrofia del riñón afecto, que precisó importante soporte inotrópico y antihipertensivo durante los primeros días de vida, con importante mejoría clínica posterior.

Diagnosis and management of systemic hypertension due to renovascular and aortic stenosis in patients with Williams-Beuren syndrome

SUMMARY AIM To describe the incidence, diagnosis, and management of systemic arterial hypertension related to renal artery stenosis in patients with Williams-Beuren syndrome. METHODS Sixty-five patients with Williams-Beuren syndrome were evaluated for hypertension. Enrolled patients underwent Doppler sonography of the renal arteries and Doppler echocardiography. Those with Doppler sonography-detected lesions or with normal Doppler sonography but severe hypertension underwent computed tomography or gadolinium-enhanced magnetic resonance angiography of the aorta and renal vessels. Patients needing vascular therapeutic intervention underwent conventional angiography. RESULTS Systemic arterial hypertension was diagnosed in 21/65 patients with Williams-Beuren syndrome (32%; 13 male) with a mean age of 13.9 years (5mo-20yrs). In 8/21 patients renovascular hypertension was detected. Angioplasty was unsuccessful in five patients with renal artery stenosis, requiring additional treatment. Doppler echocardiography showed cardiac abnormalities in 16/21 (76%) hypertensive patients. CONCLUSION Cardiac abnormalities and hypertension in patients with Williams-Beuren syndrome are common. Thus, thorough evaluation and follow-up are necessary to reduce cardiovascular risks and mortality of these patients

RESUMO OBJETIVO Descrever a incidência, o diagnóstico e o tratamento da hipertensão arterial sistêmica relacionada com estenose da artéria renal em pacientes com síndrome de Williams-Beuren. MÉTODOS Sessenta e cinco pacientes com síndrome de Williams-Beuren foram avaliados quanto à presença de hipertensão. Os pacientes foram submetidos à ultrassonografia com Doppler das artérias renais e ecocardiograma Doppler. Aqueles com suspeita de hipertensão renovascular foram submetidos à tomografia computadorizada ou angiografia por ressonância magnética da aorta e vasos renais ou angiografia convencional. RESULTADOS A hipertensão arterial sistêmica foi diagnosticada em 21/65 pacientes com síndrome de Williams-Beuren (32%, 13 do sexo masculino), com idade média de 13,9 anos (5 meses-20 anos). Em 8/21 pacientes foi detectada a hipertensão renovascular. Angioplastia não teve sucesso em cinco pacientes com estenose da artéria renal, necessitando de tratamento adicional. O ecocardiograma Doppler mostrou anormalidades cardíacas em 16/21 (76%) pacientes hipertensos. CONCLUSÃO As anormalidades cardíacas e hipertensão arterial em pacientes com síndrome de Williams-Beuren são muito frequentes, sendo necessários uma avaliação minuciosa e seguimento para diminuir o risco cardiovascular e a morbimortalidade desses pacientes

Dissecção espontânea da artéria renal: relato de caso / Spontaneous dissection of the renal artery: case report

A dissecção espontânea da artéria renal é uma patologia rara que, na maioria dos casos, ocorre de forma idiopática. Em alguns casos, pode estar associada à presença de alterações arteriais prévias. Os sintomas geralmente são discretos e inespecíficos, dificultando o diagnóstico. Os autores relatam o caso de um paciente do sexo masculino, de 40 anos, com quadro de hipertensão arterial não controlada de início recente. Na investigação da etiologia da hipertensão arterial, o eco-Doppler de artérias renais revelou a presença de estenose (> 80%) no terço médio da artéria renal esquerda, e a angiografia evidenciou uma dissecção com dupla luz e redução do calibre do vaso. O paciente foi submetido a tratamento com implante de stent com evolução satisfatória.

Spontaneous renal artery dissection is rare and most cases are considered idiopathic. Previous renal arterial disease may be present in some cases and clinical presentation is often non-specific. Here, the authors present a case of spontaneous renal artery dissection in a 40-year-old male patient with uncontrolled hypertension discovered during investigation of secondary hypertension. Duplex ultrasound initially showed 80% left renal artery stenosis which was shown to be a renal artery dissection during angiography. The patient was successfully managed by percutaneous placement of a renal artery stent.

Diagnosis and management of systemic hypertension due to renovascular and aortic stenosis in patients with Williams-Beuren syndrome.

AIM: To describe the incidence, diagnosis, and management of systemic arterial hypertension related to renal artery stenosis in patients with Williams-Beuren syndrome. METHODS: Sixty-five patients with Williams-Beuren syndrome were evaluated for hypertension. Enrolled patients underwent Doppler sonography of the renal arteries and Doppler echocardiography. Those with Doppler sonography-detected lesions or with normal Doppler sonography but severe hypertension underwent computed tomography or gadolinium-enhanced magnetic resonance angiography of the aorta and renal vessels. Patients needing vascular therapeutic intervention underwent conventional angiography. RESULTS: Systemic arterial hypertension was diagnosed in 21/65 patients with Williams-Beuren syndrome (32%; 13 male) with a mean age of 13.9 years (5mo-20yrs). In 8/21 patients renovascular hypertension was detected. Angioplasty was unsuccessful in five patients with renal artery stenosis, requiring additional treatment. Doppler echocardiography showed cardiac abnormalities in 16/21 (76%) hypertensive patients. CONCLUSION: Cardiac abnormalities and hypertension in patients with Williams-Beuren syndrome are common. Thus, thorough evaluation and follow-up are necessary to reduce cardiovascular risks and mortality of these patients.

Intermittent claudication and severe renal artery stenosis are independently associated in hypertensive patients referred for renal arteriography.

OBJECTIVE:: The purpose of this study was to evaluate the association between the presence of clinical symptoms of peripheral artery disease and severe renal artery stenosis in patients referred for renal angiography. METHOD:: We included 82 patients with clinical suspicion of renovascular hypertension and performed an imaging investigation (renal Doppler ultrasound and/or renal scintigraphy) for possible renal artery stenosis. All patients underwent renal arteriography and were examined for peripheral artery disease based on the presence of intermittent claudication and ankle-brachial index test results. Severe renal artery stenosis was defined as a lesion causing 70% obstruction. RESULTS:: Severe renal artery stenosis was present in 32 of 82 (39%) patients. Patients with severe renal artery stenosis were older (63±12 vs 56±12 years, p=0.006), had more intermittent claudication (55 vs 45%, p=0.027), and had a greater prevalence of an ankle-brachial index <0.9 (44% vs 20%, p=0.021) than patients without severe renal artery stenosis. Multivariate logistic regression analysis showed that the presence of intermittent claudication was independently associated with renal artery stenosis ≥70% (OR: 3.33; 95% CI 1.03-10.82, p=0.04), unlike the ankle-brachial index, which showed no association (OR: 1.44; 95% CI 0.37-5.66, p=0.60). CONCLUSION:: Intermittent claudication is independently associated with severe renal artery stenosis (≥70%) in patients clinically suspected of having renovascular hypertension.

Low-energy shock wave preconditioning reduces renal ischemic reperfusion injury caused by renal artery occlusion.

PURPOSE:: To evaluate whether low energy shock wave preconditioning could reduce renal ischemic reperfusion injury caused by renal artery occlusion. METHODS:: The right kidneys of 64 male Sprague Dawley rats were removed to establish an isolated kidney model. The rats were then divided into four treatment groups: Group 1 was the sham treatment group; Group 2, received only low-energy (12 kv, 1 Hz, 200 times) shock wave preconditioning; Group 3 received the same low-energy shock wave preconditioning as Group 2, and then the left renal artery was occluded for 45 minutes; and Group 4 had the left renal artery occluded for 45 minutes. At 24 hours and one-week time points after reperfusion, serum inducible nitric oxide synthase (iNOS), neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), creatinine (Cr), and cystatin C (Cys C) levels were measured, malondialdehyde (MDA) in kidney tissue was detected, and changes in nephric morphology were evaluated by light and electron microscopy. RESULTS:: Twenty-four hours after reperfusion, serum iNOS, NGAL, Cr, Cys C, and MDA levels in Group 3 were significantly lower than those in Group 4; light and electron microscopy showed that the renal tissue injury in Group 3 was significantly lighter than that in Group 4. One week after reperfusion, serum NGAL, KIM-1, and Cys C levels in Group 3 were significantly lower than those in Group 4. CONCLUSION:: Low-energy shock wave preconditioning can reduce renal ischemic reperfusion injury caused by renal artery occlusion in an isolated kidney rat model.

Intermittent claudication and severe renal artery stenosis are independently associated in hypertensive patients referred for renal arteriography

OBJECTIVE: The purpose of this study was to evaluate the association between the presence of clinical symptoms of peripheral artery disease and severe renal artery stenosis in patients referred for renal angiography. METHOD: We included 82 patients with clinical suspicion of renovascular hypertension and performed an imaging investigation (renal Doppler ultrasound and/or renal scintigraphy) for possible renal artery stenosis. All patients underwent renal arteriography and were examined for peripheral artery disease based on the presence of intermittent claudication and ankle-brachial index test results. Severe renal artery stenosis was defined as a lesion causing 70% obstruction. RESULTS: Severe renal artery stenosis was present in 32 of 82 (39%) patients. Patients with severe renal artery stenosis were older (63±12 vs 56±12 years, p=0.006), had more intermittent claudication (55 vs 45%, p=0.027), and had a greater prevalence of an ankle-brachial index <0.9 (44% vs 20%, p=0.021) than patients without severe renal artery stenosis. Multivariate logistic regression analysis showed that the presence of intermittent claudication was independently associated with renal artery stenosis ≥70% (OR: 3.33; 95% CI 1.03-10.82, p=0.04), unlike the ankle-brachial index, which showed no association (OR: 1.44; 95% CI 0.37-5.66, p=0.60). CONCLUSION: Intermittent claudication is independently associated with severe renal artery stenosis (≥70%) in patients clinically suspected of having renovascular hypertension.

Low-energy shock wave preconditioning reduces renal ischemic reperfusion injury caused by renal artery occlusion

Abstract Purpose: To evaluate whether low energy shock wave preconditioning could reduce renal ischemic reperfusion injury caused by renal artery occlusion. Methods: The right kidneys of 64 male Sprague Dawley rats were removed to establish an isolated kidney model. The rats were then divided into four treatment groups: Group 1 was the sham treatment group; Group 2, received only low-energy (12 kv, 1 Hz, 200 times) shock wave preconditioning; Group 3 received the same low-energy shock wave preconditioning as Group 2, and then the left renal artery was occluded for 45 minutes; and Group 4 had the left renal artery occluded for 45 minutes. At 24 hours and one-week time points after reperfusion, serum inducible nitric oxide synthase (iNOS), neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), creatinine (Cr), and cystatin C (Cys C) levels were measured, malondialdehyde (MDA) in kidney tissue was detected, and changes in nephric morphology were evaluated by light and electron microscopy. Results: Twenty-four hours after reperfusion, serum iNOS, NGAL, Cr, Cys C, and MDA levels in Group 3 were significantly lower than those in Group 4; light and electron microscopy showed that the renal tissue injury in Group 3 was significantly lighter than that in Group 4. One week after reperfusion, serum NGAL, KIM-1, and Cys C levels in Group 3 were significantly lower than those in Group 4. Conclusion: Low-energy shock wave preconditioning can reduce renal ischemic reperfusion injury caused by renal artery occlusion in an isolated kidney rat model.

Takayasu's arteritis with renal artery stenosis diagnosed in a patient with 65 years old.

Takayasu arteritis is a rare disease of unknown etiology that affects the aorta and its main branches. It is a condition, geographically more common in Southeast Asia, which mainly affects women of reproductive age. The clinical presentation is nonspecific, with signs and symptoms that vary according to the affected arterial segment. The most commonly affected vessel is the subclavian artery, while renal artery stenosis is relatively uncommon. Cardiac involvement and association with other diseases may also be present. We present in this report the case of an elderly patient with late diagnosis of Takayasu's arteritis and various comorbidities or related complications.

Arterite de Takayasu com estenose de artéria renal diagnosticada em paciente com 65 anos de idade / Takayasu's arteritis with renal artery stenosis diagnosed in a patient with 65 years old

Resumo Arterite de Takayasu é uma doença rara, de etiologia desconhecida, que acomete a aorta e seus principais ramos. É uma patologia, geograficamente mais comum no Sudeste Asiático, que acomete principalmente mulheres em idade reprodutiva. A apresentação clínica é inespecífica, com sinais e sintomas que variam de acordo com o seguimento arterial acometido. O vaso mais comumente afetado é a artéria subclávia, enquanto a estenose de artéria renal é relativamente incomum. Comprometimento cardíaco e associação com outras patologias também podem estar presentes. Apresentamos neste relato o caso de uma paciente idosa com diagnóstico tardio de arterite de Takayasu e várias comorbidades ou complicações relacionadas.

Abstract Takayasu arteritis is a rare disease of unknown etiology that affects the aorta and its main branches. It is a condition, geographically more common in Southeast Asia, which mainly affects women of reproductive age. The clinical presentation is nonspecific, with signs and symptoms that vary according to the affected arterial segment. The most commonly affected vessel is the subclavian artery, while renal artery stenosis is relatively uncommon. Cardiac involvement and association with other diseases may also be present. We present in this report the case of an elderly patient with late diagnosis of Takayasu's arteritis and various comorbidities or related complications.

Abordagem endovascular de paciente com fibrodisplasia de artéria renal bilateral associada a volumoso aneurisma renal / Endovascular approach of a patient with bilateral renal artery fibrodysplasia associated with a massive renal aneurysm

A fibrodisplasia muscular renal é de etiologia desconhecida, de origem não inflamatória e não aterosclerótica, estando associada ao desenvolvimento de estenoses e de aneurismas. Relatamos um caso de fibrodisplasia muscular renal bilateral associada a aneurisma volumoso de artéria renal tratado com angioplastia com balão e stent multicamadas.

Renal artery fibromuscular dysplasia is a condition of unknown etiology, with non-inflammatory, nonatheroscleroticorigin, associated to the development of stenosis and aneurysms. The authors report a case of bilateral renal artery fibromuscular dysplasia associated with a large renal artery aneurysm, treatedwith balloon angioplasty and a multilayer stent.

Current approaches to atherosclerotic obstructive renal artery stenosis.

Increased lifespan in the last few decades has substantially changed the scenario for renal artery stenosis. Indeed, because older populations show a higher prevalence of atherosclerotic disease, the incidence of atheromatous renal artery stenosis has also increased. Intuitively, one could surmise that stenosis removal should void both the hypertension and the kidney damage resulting from the obstructive stenosis. Surprisingly, a number of important clinical trials have failed to show the reversion seen in experimental models. The reasons for these differences may be linked to chronicity and inflammation associated with the atherosclerotic lesion. However, the failure to obtain a favorable response may also be related to abnormalities in the contralateral kidney. Indeed, this apparently normal kidney should work to compensate the hemodynamic effects of the ipsilateral stenosed kidney. Instead, structure and function in the contralateral kidney can be altered in renal artery stenosis to the point that this nonstenotic kidney may sustain both, hypertension and progressive kidney disease. Certainly, comparing the effects of clip removal in the Goldblatt model to angioplasty in clinical settings with atherosclerotic lesions may be totally inappropriate. Nevertheless, there remain certain clinical situations such as bilateral renal arterial disease, congestive heart failure, and progressive renal failure, where angioplasty may be an alternative. These approaches however are yet to be tested.

O tratamento da hipertensão renovascular frente aos resultados dos novos estudo / Treatment of renovascular hypertension in light of the results of new studies

O presente artigo revisa o importante papel na escolha da melhor opção de tratamento da hipertensão arterial de etiologia renovascular. Infelizmente a luz das últimas e mais atuais evidências científicas não houve diferença significativa entre as duas modalidades terapêuticas mais utilizadas, tratamento medicamentoso versus tratamento intervencionista percutâneo, na redução da morbidade e mortalidade cardiovascular do paciente com hipertensão arterial e estenose de artéria renal. Sabe-se, porém, que a doença renovascular quando presente em pacientes com perda progressiva da função renal, naqueles com edema agudo de pulmão de repetição, nos pacientes com doença arterial coronária ou disfunção ventricular esquerda onde um melhor controle da pressão arterial é necessário e o mesmo não é alcançado apesar do adequado tratamento medicamentoso, a intervenção percutânea se impõe. É certo que, independente da opção terapêutica utilizada, é necessário que todas as comorbidades presentes sejam corrigidas para que melhores resultados finais sejam alcançados. A investigação precoce baseada em critérios clínicos de probabilidade somada ao auxílio de exames complementares permitirão maiores chances de acerto diagnóstico, cuja certeza só existirá após a realização da intervenção escolhida. Infelizmente a certeza que hoje temos em relação à opção diagnóstica mais adequada não existe quanto aos resultados tardios, exceto nas condições já exposta.

This article reviews the important role of the choice of best treatment option for arterial hypertension of renovascular etiology. Unfortunately, according to the latest and most upto-date scientific evidence, there is no significant difference between the two most commonly used modes of therapy: drug treatment vs. percutaneous interventionist treatment,in reducing cardiovascular morbidity and mortality in patients with arterial hypertension and stenosis of the renal artery. However, it is known that in renovascular disease, when present in patients with progressive loss of renal function, in those with acute repetition edema of the lung, and in those with coronary arterial disease or left ventricular dysfunction, where better control of blood pressure is necessary but is not achieved despite adequate drug treatment, percutaneous intervention is necessary. Undoubtedly, regardless of the therapeutic option used, it is necessary for all the comorbidities present to be corrected, in order to improve the final results. Early investigation based on clinical criteria of probability, with the aid of complementary exams, will result in higher chances of obtaining the correct diagnosis, which will only be certain after the chosen intervention has been carried out. Unfortunately, the certainty that we have today as to the most appropriate diagnostic options is not borne out in the most recent results, except in the conditions mentioned above.

Effect of renal revascularization on the development of renal dysfunction in atherosclerotic ischemic nephropathy.

Chronic kidney disease (CKD) is characterized by a progressive loss of renal function and its main causes are hypertension and diabetes mellitus. Among the causes of hypertension is atherosclerotic renal disease (ARD). The development of CKD in patients with ARD appears to be due not only to the involvement of the main renal arteries, but also of the renal microcirculation, which may explain the fact that the success of the procedure does not guarantee an improvement in the progression of CKD. To date there is no evidence of benefit of angioplasty compared to medical treatment alone in patients with ARD. The present paper analyzes the most significant studies on renal outcomes in patients with ARD undergoing revascularization or medical treatment alone.

[Aneurysmal rupture complicating aortitis: a case report]. / Aortite polyanévrismale compliquée de rupture : à propos d'un cas.

Tropical aortitis is a rare and poorly described aortic disease, sometimes confounded with Takayasu's disease, mainly in people from Africa. In this case report, the panaortic aneurysmal disease in a young woman from Haiti, first diagnosed after a work-up on renovascular hypertension, would appear to approach this particular arterial disease with no clinical, radiological or biological argument for an infectious etiology. The initially suspected diagnosis of Takayasu's disease had to be rethought because of the presence of several saccular aneurysms extending from the aortic arch to the infrarenal aorta, rarely described in Takayasu's aortitis. Expert opinions from vascular surgeons and clinicians tagged this aortic disease as similar to tropical aortitis which remained asymptomatic for more than a decade. Hypertension was managed with successful balloon angioplasty of the left renal artery stenosis and anti-hypertensive combination therapy. Surgical management of the extended aortic aneurysms was not proposed because of the stability and asymptomatic nature of the aneurysmal disease and the high risk of surgical morbidity and mortality. More than ten years after diagnosis, the course was marked with inaugural and sudden-onset chest pain concomitant with contained rupture of the descending thoracic aortic aneurysm. This case report underlines the persistent risk of aneurysmal rupture and the importance of an anatomopathological study for the diagnosis of complex aortic disease.

Renal artery stenosis predicts coronary artery disease in patients with hypertension.

In hypertensive patients with indication of renal arteriography to investigate renal artery stenosis (RAS) there are no recommendations regarding when to investigate coronary artery disease (CAD). Moreover, the predictors of CAD in patients with RAS are not clear. We aimed to evaluate the frequency and the determinants of CAD in hypertensive patients referred to renal angiography. Eighty-two consecutive patients with high clinical risk suggesting the presence of RAS systematically underwent renal angiography and coronary angiography during the same procedure. Significant arterial stenosis was defined by an obstruction ≥ 70% to both renal and coronary territories. Significant CAD was present in 32/82 (39%) and significant RAS in 32/82 (39%) patients. Both CAD and RAS were present in 25.6% from the 82 patients. Patients with severe CAD were older (63 ± 12 vs. 56 ± 13 years; p = 0.03) and had more angina (41 vs. 16%; p = 0.013) compared to patients without severe CAD. Significant RAS was associated with an increased frequency of severe CAD compared to patients without significant RAS (66% vs. 22%, respectively; p<0.001). Myocardial scintigraphy showed ischemia in 21.8% of the patients with CAD. Binary logistic regression analysis showed that RAS ≥ 70% was independently associated with CAD ≥ 70% (OR: 11.48; 95% CI 3.2-40.2; p<0.001), even in patients without angina (OR: 13.48; 95%CI 2.6-12.1; p<0.001). Even considering a small number of patients with significant RAS, we conclude that in hypertensive patients referred to renal angiography, RAS ≥ 70% may be a strong predictor of severe CAD, independently of angina, and dual investigation should be considered.

Nefropatia isquêmica / Ischemic nephropathy

A doença renal isquêmica ou nefropatia isquêmica relacionada à doença renovascular pode evoluir de forma rápida e progressiva para a insuficiência renal crônica. É fundamental a identificação e o tratamento precoces desta condição clínica, prevenindo a ocorrência de doença renal em estágio terminal, com consequente necessidade de terapia de substituição renal. Há uma década, o controle da hipertensão renovascular era o objetivo primário no manejo de pacientes com doença renovascular. Atualmente, a meta está dirigida principalmente para a estabilização e a melhora da função renal, além do controle dos níveis pressóricos.

Ischemic renal disease or ischemic nephropathy related to renovascular disease can progress rapidly and gradually to chronic renal failure. Early diagnosis and treatment is crucial for this clinical condition, because they can prevent occurrence of end-stage renal disease, with consequent need for renal replacement therapy. A decade ago, renovascular hypertension control was the primary objective in the management of patients with renovascular disease. Currently, the goal is addressed primarily to the stabilization and improvement of renal function, in addition to blood pressure control.