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Differences in clinical findings before unilateral and bilateral renal artery stenosis 

Differences in clinical findings before unilateral and bilateral renal artery stenosis 

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In 1988 Pickering et al . reported in the Lancet a series of 11 hypertensive patients with bilateral atheromatous renovascular disease who presented with a history of multiple episodes of pulmonary oedema.1 Seven of these patients had stenosis of both renal arteries and in a subsequent series of 90 patients, pulmonary oedema was significantly more...

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... The hallmark 'flash pulmonary oedema' is a well-recognised manifestation of renal artery disease. Flash pulmonary oedema (or Pickering syndrome) is a general term used to describe a hyper-acute presentation of decompensated heart failure due to an acute rise of left ventricular end diastolic pressure.Although it has become synonymous with bilateral severe RAS or severe RAS affecting a solitary kidney, prompting the physician to consider screening for this underlying arterial pathology [12], it can also present in patients with other conditions such as acute coronary syndrome. Previous reports from this unit have illustrated that patients presenting with heart failure syndromes, such as flash pulmonary oedema, if managed medically, have an increased risk for death and cardiovascular events but not for progression to end stage kidney disease. ...
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Background Atherosclerotic renovascular disease (ARVD) often follows an asymptomatic chronic course which may be undetected for many years. However, there are certain critical acute presentations associated with ARVD and these require a high index of suspicion for underlying high-grade RAS (renal artery stenosis) to improve patient outcomes. These acute presentations, which include decompensated heart failure syndromes, accelerated hypertension, rapidly declining renal function, and acute kidney injury (AKI), are usually associated with bilateral high-grade RAS (> 70% stenosis), or high-grade RAS in a solitary functioning kidney in which case the contralateral kidney is supplied by a vessel demonstrating renal artery occlusion (RAO). These presentations are typically underrepresented in large, randomized control trials which to date have been largely negative in terms of the conferred benefit of revascularization. Case presentation Here we describe 9 individual patients with 3 classical presentations including accelerated phase hypertension, heart failure syndromes, AKI and a fourth category of patients who suffered recurrent presentations. We describe their response to renal revascularization. The predominant presentation was that consistent with ischaemic nephropathy all of whom had a positive outcome with revascularization. Conclusion A high index of suspicion is required for the diagnosis of RAS in these instances so that timely revascularization can be undertaken to restore or preserve renal function and reduce the incidence of hospital admissions for heart failure syndromes.
... Renal artery stenosis should be suspected in case of non-dipping pattern findings during 24 h ABPM, rapid progression of arterial hypertension, impaired renal function, and recurrent fulminant pulmonary edema (Pickering syndrome). These patients should be screened for renal artery stenosis by ultrasound, computed tomography, or magnetic resonance (29,30). ...
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Treatment-resistant hypertension is one of the most significant causes of poor blood pressure regulation. Patients with resistant hypertension are at a higher risk of developing comorbidities compared to the general hypertensive population. As a result, these patients have an increased incidence of disability and premature death, as well as increased treatment costs. Due to the above-mentioned, in the last decade, there has been an increase in researchers' interest in elucidating the pathogenesis, diagnosis, and treatment of resistant hypertension. However, recent data indicate that 20% of female and 24% of male patients with arterial hypertension still have uncontrolled blood pressure, despite maximum doses of three antihypertensive drugs (including a diuretic) and appropriate lifestyle measures. New treatment modalities (i.e. devicebased interventions - catheter-based renal denervation and baroreceptor stimulation) offer hope for achieving adequate blood pressure regulation in these patients. In this paper, we have summarized previous knowledge about the mechanisms underlying the pathogenesis of resistant hypertension, as well as optimal diagnostic methods to differentiate true from pseudo-resistant hypertension. We have also given an overview of the current therapeutic approach, including optimal medical therapy and new treatment modalities (i.e. device-based interventions) and their role in the treatment of resistant hypertension.
... Hypokalemia, presence of an abdominal bruit, and diagnosis of hypertension at an unusually young age are some classic features associated with RAS. 2 Acute onset decompensated heart failure, also known as flash pulmonary edema, is a presentation that is usually associated with bilateral RAS or RAS affecting a solitary functioning kidney. 15 American Heart Association (AHA) guidelines describe several clinical scenarios where RAS should be suspected and excluded. 13 Six scenarios are given below: ...
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Renal artery stenosis (RAS) is associated with hypertension and renal impairment. Atherosclerosis is the leading etiologic factor which accounts for >90% of the cases. Those with atherosclerotic RAS (ARAS) tend to have concomitant atherosclerosis in other vascular beds, so they are at a high risk of adverse coronary and cerebrovascular events. Management of ARAS is controversial, with limited indications for revascularization. In this review, the author aims to discuss the pathophysiology, natural history, diagnosis, and management of ARAS.
... Which would tend to counter the development of pulmonary edema but in patients with bilateral stenosis this effect would be reduced because the kidneys would not be exposed to the systemic pressure? (Figure 5) [8]. It is only because the specific symptom of pulmonary edema was improved by angioplasty or renal artery bypass graft that the relationship between the renal artery narrowing and the pathophysiological condition was established. ...
... Haemodynamic unloading by antihypertensive drugs usually result in prompt resolution of FPO. In Phase 2, once the patient is out of pulmonary oedema and has been stabilized, renal revascularization is the treatment of choice, since the pathophysiology of the Pickering Syndrome is characterized by the inability to generate a pressure natriuresis due to renal hypoperfusion [2,8]. The fact that the response to renal artery angioplasty has been excellent and patient became asymptomatic strongly supports the argument that the pulmonary edema was secondary to bilateral renal artery stenosis and not due to left ventricular dysfunction which in fact has improved following renal angioplasty. ...
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Flash Pulmonary Edema (FPE) is a type of recurrent pulmonary edema that usually develops in patients with critical bilateral renal artery stenosis (RAS) or renal artery stenosis to a solitary kidney. A recent recommendation from the 20th European Meeting on Hypertension proposes naming this clinical entity Pickering Syndrome. Currently, it is one of the few clear indications for endovascular procedures in atherosclerotic renovascular disease. We present a case of a 45-year old female with Pickering syndrome and good outcome after revascularization. Keywords: Pulmonary Edema; Natriuresis; Pulmonary; Revascularization
... How ever, despite optimal pharmacological management or invasive intervention, patients with significant ARAS have a higher risk of acute cardiovascular episodes than individuals without renal stenosis. This group is characterized by more frequent occurrence of heart failure (HF), myocardial infarction (MI), stroke and death for any reason [11][12][13][14][15][16][17][18][19][20][21][22][23]. However, so far, few studies have included patients with non-significant renal artery stenosis (NS-RAS), and none of the reviewed studies included NS-RAS diagnosed by ultrasound. ...
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Introduction The interactions between ARAS, independent on severity, and cardiovascular risk, and mortality are complex and not fully researched. The aim of this study was the assessment of the risk of cardiovascular events and mortality in patients with hemodynamically non-significant (NS-RAS) and significant renal artery stenosis (S-RAS) diagnosed with ultrasonography. Material and methods The study group consisted of all consecutive patients (n = 2,059) who underwent Doppler ultrasound of the renal arteries during a four years’ time. The patients were divided, according to the renal aortic ratio (RAR) into: hemodynamically significant RAS (S-RAS; RAR ≥ 3.5), hemodynamically non-significant RAS (NS-RAS; 1 < RAR < 3.5) and normal RAR (control group; RAR ≤ 1). The risk of cardiovascular events and death was estimated using Cox’s proportional hazard model including severity of RAS, age and gender, based on the data from the National Health Fund on causes of hospitalization, deaths and statistics on percutaneous coronary angioplasty procedures. Results S-RAS was found in 112 patients (5.4 %), NS-RAS in 313 patients (15.2 %) and 1634 patients (79.4 %) were qualified to control group. NS-RAS group had an increased risk of stroke (7.0 % vs. 3.0 %; HR 1.77; p = 0.032). S-RAS patients were at increased risk of heart failure (16.1 % vs. 5.2 %, HR 2.19; p = 0.002) and death (19.6 % vs. 4.3 %; HR 3.08; p < 0.001). Conclusions The presence of hemodynamically non-significant renal artery stenosis is an indicator of systemic atherosclerotic changes in vital organs and an important cardiovascular risk factor for stroke.
... The distinguishing factor for SCAPE from other forms of decompensated heart failure is the acute increase of LV end diastolic pressure which floods of the alveolar space within minutes resulting in an acute life-threatening emergency. 5 The risk factors associated with heart failure such as hypertension, coronary ischaemia, valvular heart disease and diastolic dysfunction are associated with development of SCAPE. In our case, the patient had no such previous history and further evaluation in the hospital revealed a bilateral RAS. ...
... This clinical entity was later named as pickering syndrome, in honour to the author. 5 Bilateral RAS can lead to SCAPE by three main pathophysiological mechanisms: ...
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Sympathetic crash acute pulmonary edema (SCAPE) is a life-threatening injury, which requires early recognition and intervention to prevent mortality. We present a case of 18-year-old woman with no previous comorbidity, presenting with SCAPE who was successfully resuscitated and eventually diagnosed with renal artery stenosis. Pickering syndrome is a rare cause of hypertensive emergency and should be considered in a young patient presenting with SCAPE in emergency department.
... Several factors can cause TRAS, which will depend on the location and the time between transplantation. When stenosis occurs later after transplantation, it most commonly reveals atherosclerotic disease either of the renal transplant artery or the proximal iliac artery [10]. Prox-TRAS is uncommon, but its clinical symptoms are similar to those of TRAS and usually appear later after transplantation in patients with atherosclerotic disease. ...
... La forma más común de presentación clínica es la hipertensión arterial refractaria a tratamiento médico, aunque también puede presentarse como un aumento de la creatinina sérica sin evidencia de hidronefrosis ni de infección urinaria o retención aguda de líquidos [1,2,22]. Se produce una activación del sistema renina-angiotensina-aldosterona (SRAA), de forma similar a la que ocurre con la estenosis de la arteria renal bilateral o unilateral en pacientes monorrenos; con la consiguiente retención de sodio y agua, pudiendo desarrollar edema periférico, insuficiencia cardíaca congestiva o edema agudo de pulmón [25]. ...
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INTRODUCTION: Transplant renal artery stenosis is a recognized complication of kidney transplantation associated with allograft dysfunction and even graft loss. It is a commonly missed but potentially treatable complication that may present from months to years after transplant surgery. Its prompt diagnosis and adequate therapeutic management are essential to avoid renal function loss. MATERIAL AND METHODS: We retrospectively analysed the data from two 72-year-old patients transplanted in 2017 at our institution. Both with arterial hypertension, chronic ischemic heart disease and end-stage renal disease due to nephroangiosclerosis and membranous glomerulonephritis, respectively; presented allograft dysfunction in the immediate postoperative period. With this finding and the evidence of peak systolic velocity of >200 cm/s in the transplant renal artery we suspected transplant renal artery stenosis, confirmed by angiography and CT scan. An endovascular management with stent placement was performed. RESULTS: Both patients were managed by percutaneous transluminal renal angioplasty and stent placement with good morphological outcomes. After the procedure both patients presented a progressive renal function improvement, being discharged after 8 and 11 days, respectively. Since then, both patients have remained with stable renal function, presenting a glomerular filtration rate of 67 mL/min/1.73m2 and 60 mL/min/1.73m2 12 months after the surgery. No complications have been noticed after 14 months. CONCLUSION: Percutaneous transluminal renal angioplasty and stent placement is an effective and safe technique. Nevertheless, high experience is mandatory to reduce the number of complications and optimize the results of this technique.
... RAS is associated with progressive ischemic nephropathy, hypertension, left ventricular hypertrophy, congestive heart failure, and pulmonary edema, also known as Pickering syndrome [5]. The diagnosis is made by duplex ultrasound, renal arteriography, magnetic resonance angiography, or computed tomography angiography [1]. ...
Article
Purpose To determine the therapeutic efficiency of percutaneous revascularization in renal artery stenosis (RAS), as well as the role of comprehensive factors such as patient selection and degree of artery stenosis, on clinical outcome. Methods and Materials 101 patients with hemodynamically relevant RAS underwent percutaneous angioplasty (PTA). 65.7 % were male (mean age: 64 years; range: 18–84). The clinical data was retrospectively analyzed. The serum creatinine (Cr), glomerular filtration rate (GFR), and blood pressure (BP) levels pre- and postprocedural, between 6 months and 1 year, were retrospectively collected and statistically analyzed. Results Follow-up data was available in 34 (33.7 %) and 28 patients (27.7 %) for Cr and MAP, respectively. A significant drop in mean arterial pressure (MAP) was observed on follow-up (mean –5.27 mmHg). Higher baseline Cr and MAP values showed a more pronounced drop in the follow-up (Cr: p 0.002; difference to baseline –0.25 mg/dL, 95 %CI:–0.36, –0.07 and BP p < 0.001; diff. to baseline –0.72 mmHg; 95 %CI: –1.4, –0.40). There was no association between comorbidities, gender, and degree of stenosis with renal and BP outcome. No significant improvement in renal function was observed on follow-up (mean Cr drop: –0.015 mg/dL). The age group 51–60 years showed a significant improvement in BP (p 0.030; diff. to baseline –19.2 mmHg; 95 %CI: –34, –4.3). There was a slight reduction in antihypertensive medication following angioplasty (0.2 fewer). Minor complications were recorded in five procedures (4.9 %). Conclusion Percutaneous renal artery revascularization in the presence of atherosclerotic RAS is a safe procedure associated with a significant drop in post-procedural BP. No significant improvement in renal function was observed. Further prospective studies focused on patient selection are necessary. Key Points: Citation Format
... TRAS may cause symptoms of hypertension, systemic edema, or heart failure posttransplantation because of water and sodium retention due to the activation of the renin-angiotensin system and the sympathetic nervous system [9]. The plasma renin activity test is not usually performed for TRAS diagnosis. ...
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Transplant renal artery stenosis (TRAS) is one cause of allograft dysfunction. TRAS causes parenchymal necrosis and graft insufficiency. Herein, we report the case of a 40-year-old female with end-stage renal disease due to immunoglobulin A nephropathy, who underwent kidney transplantation with her elder sister. The surgery was successful and the allograft showed primary graft function. At postoperative day (POD) 2, urine output decreased sharply. We checked a non-enhanced abdominal computed tomography scan which showed subcapsular and pelvic cavity hematomas. She underwent hematoma removal surgery with renal upper polar capsulotomy. Bleeding control was successful, but her serum creatinine was 5.4 mg/dL. At POD 25, abdomen magnetic resonance angiography showed significant stenosis at the anastomosis site between the graft renal artery and the recipient's internal iliac artery. Then, percutaneous transluminal angioplasty was implemented. Significant stenosis (>80%) was detected at the anastomotic site and a 5-mm stent was inserted at stenotic lesion with post-stent balloon angioplasty using a 5-mm balloon catheter. The renal arterial diameter and blood flow were normalized. At postoperative 5 months, a 99mTc dimercaptosuccinic acid scan showed multiple focal radioisotope defects. At 54 months after renal transplantation, her serum creatinine level was 4.0 mg/dL and her glomerular filtration rate was 13 mL/min/1.73 m2. Hence, we report that TRAS can cause parenchymal necrosis and allograft dysfunction.