---

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.

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):293

PART II - PROCEDURE FOLLOWED

We start from the principle that the ideal moment to treat this patient would have been on the occasion of her first hospitalization. As it has not happened, and as the result of the lack of specific treatment is known, the clinical approach we indicated was the endarterectomy of the right renal artery which had been recently thrombosed.

The surgical procedure consisted of sectioning the right renal artery at its origin and making a primary arterial radiography at the site. The kidney was maintained in a low temperature with cold Ringer's lactate solution and immediately we proceeded the eversion endarterectomy. The renal artery was reimplanted in the aorta lateral wall, 1.5 cm below its previous location (Figure 2). The renal artery was clamped for 37 minutes and the renal function recovered to the urinary volume of 120 ml in the first 24 hours, increasing in the following days, as shown in Table 1. The creatinine levels can be found in the same table. The patient was submitted to four hemodialysis sessions, the last being in the 8th postoperative day. An intercurrent blue toe developed in the right toe, with later satisfactory healing.

Figure 2 - Detail of the right renal artery (RRA) reimplantatin after eversion endarterectomy.

Table 1 - Development of the renal function in the postoperative period

Days	pre 4	pre 3	pre 2	pre 1	cir	post 1	post 2	post 3	post 4	post 5	post 6	post 7	post 8	post 9	post 10	8 m
Hemodialysis	x	x	x	-	-	x	x	-	-	x	-	-	x	-	-
Urine						120	250	550	800	600	900	1000	800	1500	1400
Creatinine		3.6		3.7		5.2	5.4	4.7	6.2	6.2	-	6.9	7.0	-	5.2	4.3

The patient is now asymptomatic, after 8 months of the surgical intervention, receiving antihypertensive drugs atenolol 100mg/day, furosemide 80 mg/day and nifedipine 60 mg/day besides an increased discharge of urine (diuresis). Creatinine level is currently 4.3 mg/dl.

The reimplantation of the right renal artery was followed with color eco-Doppler (Figure 3), which evidenced:

1. patent reimplanted renal artery;
2. peak systolic velocity (PSV) in the output of the renal artery of 140 cm/s;
3. GSV (Great Saphenous Vein) in aorta, at the renal artery aorta, of 60 cm/s;
4. GSV relation between the right renal artery and aorta < 3;
5. normal spectral curve of the intraparenchymatous flow.

Figure 3 - Color eco-Doppler with right axial cut showing the right artery reimplantation in the abdominal aorta.

COMMENTS

The case reported is a typical example of atheromatosis of the renal artery leading to renovascular hypertension and to a typical form of ischemic nephropathy with lung acute edema in two occasions.

In the event of a clinical case presenting with occluding/stenosing disease of the renal artery, the words of a person with specific clinical expertise may be extremely important. The comparison among possible choices enhances the indications for treatment, as the patient will not be given just one alternative, or its impossibility, as it happened in the first hospitalization.

This kind of surgical procedure requires a higher level of technical expertise, and a successful surgery will determine the patient's discontinuation from an hemodialysis program, bringing economic and social benefits not only for the patient, but for the whole society.