A
case of anuria developed in a patient with renovascular hypertension
(Portuguese
PDF version)
Telmo
P. Bonamigo,1 Nilon Erling Jr.,2 Márcio Luis Lucas,2
João C. Goldani3
1.
Adjunct Professor of Vascular Surgery, Fundação Faculdade
Federal de Ciências Médicas de Porto Alegre (FFFCMPA).
Chief of the Vascular Surgery Service, Santa Casa de Misericórdia
de Porto Alegre, RS, Brazil.
2. Vascular Surgery Resident, FFFCMPA, Porto Alegre, RS, Brazil.
3. Adjunct Professor of Nephrology, FFFCMPA, Porto Alegre,
RS, Brazil.
4. Cardiac surgeon, Universidade Federal do Espírito
Santo (UFES), Vitória, ES, Brazil.
Correspondence:
Dr. Telmo P. Bonamigo
Rua Coronel Bordini, 675/303
CEP 90440-001 - Porto Alegre - RS
Brazil
Tel./Fax: +55 (51) 3333.1642
E-mail: telmobonamigo@terra.com.br
J Vasc
Br 2004;3(3):288-9
PART
I - CLINICAL CASE
A 68 years-old
female, with a diagnosis of diabetes mellitus and systemic arterial hypertension
for 2 years, was admitted to the nephrology service of Santa Casa after
being assisted in another hospital with a presentation of acute lung edema.
She was dyspneic, anxious and with progressive decrease in the urine volume.
In the previous days she had been taking atenolol 200 mg/day, hydralazine
100 mg/day, methyldopa 1.5 g/day and furosemide 80 mg/day.
On physical examination the patient was overweight and in a regular general
condition. She presented with a lung congestion with stertors in both
bases and profound edema up to the thigh in the lower extremities.
A previous ecography evidenced a reduced kidney size (L: 8.2 and R: 9.4)
and left renal function impairment. Color eco-Doppler of renal arteries
showed critical stenosis of the right renal artery and left occlusion.
Laboratory examinations carried out during hospitalization were hemoglobin
10 g/dl, urea 167 mg/dl, creatinine 4.3 mg/dl, sodium 128 mEq/l, potassium
4.1 mEq/l and glucose 224 mg/dl.
After clinical measures were taken, the patient showed a good improvement
in the clinical presentation, but the creatinine level remained > 4.0
mg/dl, with endogenous creatinine clearance (ECC) of 15.8 ml/min. The
ophtalmoscopy detected hypertensive retinopathy and the ecocardiograph
examination evidenced concentric hypertrophy of the left ventricule, with
an ejection fraction of 71% and moderate mitral insufficiency.
The patient was also submitted to an arteriography, as there was an indication
for an endovascular surgery. The procedure showed the occlusion of the
left renal artery and critical stenosis of the right renal artery, besides
poor absorption of contrast by the renal parenchyma. On consultation,
the radiologist considered no benefit in performing an angioplasty of
injuries described.
After the arteriovenous fistula was performed in the left upper limb,
because there was an expectation that the patient would need to undergo
hemodialysis in the future. She was discharged from hospital with a presentation
of compensated renal insufficiency. Atenolol 200 mg/day, furosemide 80
mg/day, nifedipine 60 mg/day and clonidine 0,450 mg/day were administered.
Three months later the patient returned to the emergency department with
another symptom of acute lung edema. Pressoric levels on hospitalization
were 200 x 100 mmHg. She presented with anuria, and tests showed creatinine
of 4.9 mg/dl and urea of 172 mg/dl. After 5 days showing no answer/reaction
to the conservative treatment she was submitted to an hemodialysis treatment
three times a week. The arteriography evidenced bilateral renal arteries
occlusion. On the right side, a polar artery was identified 3 cm below
the right renal artery (Figure 1).
 Figure
1 - Arteriography
of the abdominal aorta showing the bilateral renal artery occlusion
with a probable inferior polar artery on the right side.
At this moment, a vascular surgeon was asked to assess the possibility
of a renal revascularization.
The following questions are then asked:
- What would you do in the first hospitalization?
- If the indication for an endovascular procedure was made in the
first hospitalization, would it be interesting to listen to a vascular
surgeon, so that two treatment possibilities would be acknowledged?
- Which surgical procedure could have provided a better result, at
long- and medium-term for the patient?
- What are the theoretical basis in the literature for your therapeutic
proposal?
- What is the percentage of complications associated with each procedure
proposed?
Once this patient was only managed for clinical renovascular hypertension,
and then developing thrombosis in the right renal artery, anuria and consequently
being submitted to hemodialysis, we ask:
- What would your therapeutic proposal be at this moment?
- Would it be interesting to maintain the hemodialysis for considering
the patient without renal return?
- Would you try a second opinion of an endovascular surgeon, in an
attempt to recanalize the right renal artery recently occluded? If
positive, do you know literature reports about this topic? What were
the results? And clinical management?
- Would you search for an experienced vascular surgeon opinion to
perform a conventional vascular restoration that would be absolutely
needed?
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