Case of severe hypertension and nephrotic range proteinuria

Abstract

A case of a 37-year-old man with severe hypertension and nephrotic syndrome is presented. He had a past history of hospitalization for abdominal pain, during which 2 symmetrical kidneys with normal perfusion were revealed by an abdominal CT. He also had a calf deep vein thrombosis in the past, at which time he had a prolonged partial thrombotic time which was overlooked. Kidney ultrasound with Doppler study showed a small hyperechogenic left kidney with an increased resistive index, suggesting unilateral renovascular hypertension confirmed by CT angiography, which showed occlusion of the left renal artery. The left kidney was found not contributing to the overall renal function (∼1%). Based on his history of potential vascular abdominal events, documented deep vein thrombosis in the past, and renal artery occlusion, prolonged partial thrombotic time, and presence of antiphospholipid antibodies and lupus anticoagulant, he was diagnosed as having antiphospholipid syndrome. Because of poor compliance with medical treatment, need of lifelong anticoagulation, and minor contribution of the left kidney to renal function, nephrectomy was performed. Both hypertension and proteinuria were resolved. This case reaffirms the role of renovascular hypertension in massive proteinuria as described previously,2,3,5,12-15 as well as in many other case reports, and the resolution of nephrotic syndrome and the renin excess by medical interventions or by revascularization with surgery or angioplasty, and nephrectomy as in our case. It also reaffirms the not-so-well-recognized hyponatremic hypertensive syndrome1-6 and its similar resolution. Our case also reaffirms the role of the antiphospholipid syndrome in renovascular hypertension as has been described previously.