Abstract
This report describes the clinical course, diagnostic evaluation and management of six children with bilateral renal artery stenosis (RAS) and concurrent narrowing of the abdominal aorta. Except for one child with active arteritis, the others were asymptomatic. There were no clinical or laboratory features suggesting the etiology of hypertension in four of six patients, and diagnostic procedures, including Doppler duplex ultrasound and captopril scintigraphy, were unreliable in screening for such hypertension. Abdominal aortography and selective renal angiography confirmed the diagnosis of bilateral RAS and associated anatomical alterations of the aorta and its branches. The hypertension was severe and minimally responsive to antihypertensive agents. It was cured or improved after percutaneous transluminal angioplasty (PTA) of three vessels in two children with mid-vessel stenoses, while hypertension persisted after PTA of two mid-vessel stenoses in a third child and one vessel with ostium stenosis in a fourth child. Autotransplantation of seven kidneys in four children resulted in cure or significant improvement of the hypertension. Renal function was preserved in all children during a mean follow-up time of 41 months. Based on illustrative data from these six children, as well as information from a review of the literature, this report discusses the key diagnostic issues and stresses the potential advantages of renal autotransplantation in selected children with this disorder.
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Horan MJ, Falkner B, Kimm Sue YS, Loggie JMH, Prineas RJ, Rosner B, Hutchinson J, Lauer R, Mueller S, Riopel DA, Sinaiko A, Weidman WH, Berenson G, Fixler D, Schacher J (1987) Report of the second task force on blood pressure control in children 1987. Pediatrics 79:1–25
Muller FB, Sealey JE, Case DB, Atlas SA, Pickering TG, Pecker MS, Preibisz JJ, Laragh JH (1986) The captopril test for identifying renovascular disease in hypertensive patients. Am J Med 80: 633–644
Dillon MJ, Ryness JM (1975) Plasma renin activity and aldosterone concentrations in children. BMJ 4: 316–319
Milner LS, Jacobs DW, Thomson PD, Kala UK, Franklin J, Beale P, Levin SE (1991) Management of severe hypertension in childhood Takayasu's arteritis. Pediatr Nephrol 5: 38–41
Alon U, Hellerstein S, Warady BA (1991) Clinical quiz. Pediatr Nephrol 5: 273–274
Merguerian PA, McLorie GA, Balfe JW, Khoury AE, Churchill BM (1990) Renal autotransplantation in children: a successful treatment for renovascular hypertension. J Urol 144: 1443–1445
Berkowitz JD, O'Neill JA Jr (1989) Renovascular hypertension in children. Surgical repair with special reference to the use of reinforced vein grafts. J Vasc Surg 9: 46–55
Lacombe M (1989) Surgical treatment of renal artery stenosis in children. Chir Pediatr 30: 243–248
Eke F, Balfe JW, Hardy BE (1984) Three patients with arteritis. Arch Dis Child 59: 877–883
Daniels SR, Loggie JMH, McEnery PT, Towbin RB (1987) Clinical spectrum of intrinsic renovascular hypertension in children. Pediatrics 80: 698–704
Martinez A, Novick AC, Cunningham R, Goormastic M (1990) Improved results of vascular reconstruction in pediatric and young adult patients with renovascular hypertension. J Urol 144: 717–720
Deal DE, Snell MF, Barratt TM, Dillon MJ (1992) Renovascular disease in childhood. J Pediatr 121: 378–384
Barozzi L, Pavlica P, Sabattini A, Losinno F, Dondi M, De Fabritiis A, Amato A, Zuccala A (1991) Duplex and Doppler color echocardiography for the study of renovascular hypertension. Radiol Med 81 (Torino): 642–649
Hansen KJ, Tribble RW, Reavis SW, Canzanello VJ, Craven TE, Plonk GW Jr, Dean RH (1990) Renal duplex sonography: evaluation of clinical utility. J Vasc Surg 12: 227–236
Taylor DC, Kettler MD, Moneta GL, Kohler TR, Kazmers A, Beach KW, Strandness DE Jr (1988) Duplex ultrasound scanning in the diagnosis of renal artery stenosis: a prospective evaluation. J Vasc Surg 7: 363–369
Fry WJ, Ernst CB, Stanley JC, Brink B (1973) Renovascular hypertension in the pediatric patient. Arch Surg 107: 692–698
Lawson JD, Boerth R, Foster JG, Dean RH (1977) Diagnosis and management of renovascular hypertension in children. Arch Surg 112: 1307–1316
Reintgen D, Wolfe WG, Osofsky S, Seigler HF (1981) Renal artery stenosis in children. J Pediatr Surg 16: 26–31
Davidson R, Wilcox CS (1991) Diagnostic usefulness of renal scanning after angiotensin converting enzyme inhibitors. Hypertension 18: 299–303
McGrath BP, Matthews PG, Johnston CI (1983) Use of captopril in the diagnosis of renal hypertension. Aust N Z J Med 11: 359–363
Setaro IF, Saddler MC, Chen CC, Hoffer PB, Roer DA, Markowitz DM, Meier GH, Gusberg RJ, Black HR (1991) Simplified captopril renography in diagnosis and treatment of renal artery stenosis. Hypertension 18: 289–298
Erbsloh-Muller B, Duman A, Roth D, Sfakianakis G, Bourgoignie J (1991) Furosemide-131I-hippuran renography after angiotensin-converting enzyme inhibition for the diagnosis of renovascular hypertension. Am J Med 90: 23–29
Minty I, Lythgoe MF, Gordon I (1993) Hypertension in paediatrics: can pre- and post-captopril technetium-99m dimerrcaptosuccinic acid renal scans exclude renovascular disease? Eur J Nucl Med 20: 699–702
Nally JV Jr, Black HR (1992) State-of-the-art review: captopril renography - pathophysiological considerations and clinical observations. Semin Nucl Med 2: 85–97
Debatin JF, Spritzer CE, Grist TM, Beam C, Svetkey LP, Newman GE, Sostman HD (1991) Imaging of the renal arteries: values of MR angiography. Am J Radiol 157: 981–989
Yong OY, Ma HP, Gu SB, Zhou QH, Zhang SL, Liu PZ, Zhang JY (1990) Clinical application of DSA and evaluation of its methods: analysis of 160 cases and review of the literature. Radiat Med 8: 71–78
Mann SJ, Pickering TG (1992) Detection of renovascular hypertension. Ann Intern Med 117: 845–853
Wilcox CS (1992) ACE inhibitors in the diagnosis of renovascular hypertension. Hosp Pract [Off] 27: 117–126
Gauthier B, Trachtman H, Frank R, Pillari G (1991) Inadequacy of captopril challenge test for diagnosing renovascular hypertension in children and adolescents. Pediatr Nephrol 5: 42–44
Daman Willems CE, Shah V, Uchiyama M, Dillon MJ (1989) The captopril test: an aid to investigation of hypertension. Arch Dis Child 64: 229–234
Kaufman JJ, Goodwin WE, Waisman J, Gyepes MT (1972) Renovascular hypertension in children. Report of seven cases treated surgically including two cases of renal autotransplantation. Am J Surg 124: 149–157
Stanley P, Gyepes MT, Olson DL, Gates GF (1978) Renovascular hypertension in children and adolescents. Radiology 129: 123–131
Marteau V, Sapoval M, Chaufour J, Melki JP, Cormier JM (1992) Takayasu's disease. Exploration by intra-arterial digital angiography. 50 cases. Presse Med 21: 796–799
Makker SP, Moorthy B (1979) Fibromuscular dysplasia of renal arteries: an important cause of renovascular hypertension in children. J Pediatr 95: 940–945
Watson AR, Balfe JW Hardy BE (1985) Renovascular hypertension in childhood: a changing perspective in management. J Pediatr 106: 366–372
Gavras H, Brunner HR, Thurston H, Laragh JH (1975) Reciprocation of renin dependency with sodium-volume dependency in renal hypertension. Science 188: 1316–1317
Liard JF, Cowley AW, McCaa RE, McCaa CS, Guyton AC (1974) Renin, aldosterone, body fluid volumes and the baroreceptor reflex in the development and reversal of Goldblatt hypertension in conscious dogs. Circ Res 34: 549–560
Nabel EG, Gibbons GH, Dzau VJ (1985) Patholophysiology of experimental renovascular hypertension. Am J Kidney Dis 5: A111-A119
Madias NE (1986) Renovascular hypertension. AKF Nephrol Lett 4: 27–42
Okamura T, Miyazaki M, Inagami T, Toda N (1986) Vascular renin-angiotensin system in two-kidney, one clip hypertensive rats. Hypertension 8: 560–565
Ichikawa I, Ferrone RA, Duchin KL, Manning M, Dzau VJ, Brenner BM (1983) Relative contribution of vasopressin and angiotensin II to the altered renal microcirculatory dynamics in two-kidney Goldblatt hypertension. Circ Res 53: 592–602
Franklin SS, Smith RD (1986) A comparison of enalapril plus hydrochlorothiazide with standard triple therapy in renovascular hypertension. Nephron 44 [Suppl 1]: 73–82
Hollenberg NK (1983) Medical therapy of renovascular hypertension: efficacy and safety of captopril in 269 patients. Cardiovasc Rev Rep 4: 852–876
Jackson B, McGrath BP, Matthews PG, Wong C, Johnston CI (1986) Differential renal function during angiotensin converting enzyme inhibition in renovascular hypertension. Hypertension 8: 650–654
Schalekamp MADH, Wenting GJ (1984) Angiotensin converting enzyme inhibition in renovascular hypertension: failure of the stenotic kidney. Lancet I: 464
Hodsman GP, Brown JJ, Cumming AMM (1984) Enalapril in treatment of hypertension with renal artery stenosis: changes in blood pressure, renin, angiotensin I and II, renal function, and body composition. Am J Med 77: 52–60
Canzaneloo VJ, Madaio MP, Madias NE (1987) Enalapril in the management of hypertension associated with renal artery stenosis. J Clin Pharmacol 27: 32–40
Hricik DE, Browning PJ, Kopelman R, Goorno WE, Madias NE, Dzau VJ (1983) Captopril-induced functional renal insufficiency in patients with bilateral renal-artery stenosis or renal artery stenosis in a solitary kidney. N Engl J Med 308: 373–376
Textor SC, Novick AC, Tarazi RC, Klimas V, Vidt DG, Pohl M (1985) Critical perfusion pressure for renal function in patients with bilateral atherosclerotic renal vascular disease. Ann Intern Med 102: 308–314
Jackson B, Franze L, Sumithran E, Johnston CI (1990) Pharmacologic nephrectomy with chronic angiotensin converting enzyme inhibitor treatment in renovascular hypertension in the rat. J Lab Clin Med 115: 21–27
Hricik DE (1990) Angiotensin-converting enzyme inhibition in renovascular hypertension: the narrowing gap between functional renal failure and progressive renal atrophy. J Lab Clin Med 115: 8–9
Mourad G, Ribstein J, Argiles A, Mimran A, Mion C (1989) Contrasting effects of acute angiotensin converting enzyme inhibitors and calcium antagonists in transplant renal artery stenosis. Nephrol Dial Transplant 4: 66–70
Oparil S (1986) The sympathetic nervous system in clinical and experimental hypertension. Kidney Int 30: 437–452
Ramsay LE, Waller PC (1990) Blood pressure response to percutaneous transluminal angioplasty for renovascular hypertension: an overview of published series. BMJ 300: 569–572
Chevalier RL, Tegtmeyer CJ, Gomez RA (1987) Percutaneous transluminal angioplasty for renovascular hypertension in children. Pediatr Nephrol l: 89–98
Ernst CB (1983) Childhood renovascular hypertension. Clinical approaches in high blood pressure in the young. Wright, Boston, pp 151–173
Miller GA, Ford KK, Braun SD, Newman GE, Moore AV Jr, Malone R, Dunnick NR (1985) Percutaneous transluminal angioplasty vs. surgery for renovascular hypertension. Am J Radiol 144: 447–450
Flechner SM (1984) Percutaneous transluminal dilatation. Urol Clin North Am 11: 515–527
Stanley JC (1984) Renal vascular disease and renovascular hypertension in children. Urol Clin North Am 11: 451–463
Martin LG, Price RB, Casarella WJ, Soues PJ, Wells JO Jr, Zellmer RA, Chuang VP, Silbiger ML Jr, Berkman WA (1985) Percutaneous angioplasty in clinical management of renovascu lar hypertension: initial and long-term results. Radiology 155: 629–633
Russo D, Andreucci VE, Iaccarino V, Niola R, Dal Canton A, Conte G (1988) Percutaneous renal embolisation in renovascular hypertension. BMJ 296: 1160–1161
Cooper GG, Atkinson AB, Barros D'Sa AA (1990) Simultaneous aortic and renal artery reconstruction. Br J Surg 77: 194–198
O'Mara CS, Maples MD, Kilgore TL Jr, McMullan MH, Tyler HB, Mundinger GH Jr, Kennedy RE (1988) Simultaneous aortic reconstruction and bilateral renal revascularization. Is this a safe and effective procedure? J Vasc Surg 8: 357–366
Poulias GE, Skoutas B, Doundoulakis N, Prombonas E, Papoioannou K, Mundinger GH (1987) Simultaneous aorto-renal construction and consideration to the value of combined approach. A 2-16 year follow-up study, with review of the literature. J Cardiovasc Surg 28: 688–694
Tarazi RY, Hertzer NR, Beven EG, O'Hara PJ, Anton GE, Krajewski LP (1987) Simultaneous aortic reconstruction and renal revascularization: risk factors and late results in eighty-nine patients. J Vasc Surg 5: 707–714
Rosenbaum DM, Korngold E, Teele RL (1984) Sonographic assessment of renal length in normal children. Am J Radiol 142: 467–469
Wiggelinkhuizen MBB, Cremin BJ (1978) Takayasu arteritis and renovascular hypertension in childhood. Pediatrics 62: 209–217
Cohen JR, Birnbaum E (1988) Coarctation of the abdominal aorta. J Vasc Surg 8: 160–164
Dubernard JM, Martin X, Gelet A, Mongin D, Canton F, Tabib A (1985) Renal autotransplantation versus bypass techniques for renovascular hypertension. Surgery 97: 529–534
Stoney RJ, Olofsson PA (1988) Aortorenal arterial autografts: the last two decades. Ann Vasc Surg 2: 169–173
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Ellis, D., Shapiro, R., Scantlebury, V.P. et al. Evaluation and management of bilateral renal artery stenosis in children: A case series and review. Pediatr Nephrol 9, 259–267 (1995). https://doi.org/10.1007/BF02254180
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DOI: https://doi.org/10.1007/BF02254180