Renovascular Hypertension in Chronic Hemodialytic Patient

Abstract

BACKGROUND: Hypertension is a major contributor to the development of chronic kidney disease (CKD). Data in Indonesia, hypertension is still the most comorbid disease in CKD patients on dialysis (51%). Hypertension in CKD on dialysis patients is common and often uncontrolled. Renovascular hypertension is the most common cause of secondary hypertension. Diagnosis and treatment of RAS is very important, because it can accelerate the achievement of blood pressure targets, reduce the risk and complications due to hypertension. CASE REPORT: A 52-year-old woman with CKD has been undergoing hemodialysis for 2 years. Hypertension that was previously well controlled for 2 years required an increase in antihypertensive therapy from 2 to 4 drugs in recent months. On physical examination, the blood pressure was 180/90 mmHg, pulse 79 bpm, respiration 20/min, temperature 36.7°C. Conjunctiva looks anemic, cardiomegaly, lungs within normal limits, no ascites, and edema in the extremities. On renal artery duplex ultrasound examination, right main renal artery acceleration time 147.65 ms, Peak Systolic Velocity (PSV) 31.9 cm/s. RI 0.69 and left main renal artery acceleration time 120.81 ms, PSV 16.9 cm/s, RI 0.61 supports borderline bilateral RAS. The patient underwent percutaneous transluminal renal angioplasty (PTRA). There was 20–30% left renal artery stenosis (RAS), 80% right RAS. A stent was placed on the right renal artery. The patient’s condition after PTRA improved, but blood pressure increased at the next follow-up with a mean systolic and diastolic blood pressure of 170 mmHg and 80 mmHg, respectively. The patient received four antihypertensive therapies. CONCLUSION: RAS is a disease that consists of a broad spectrum of different entities with different pathophysiologies that require varied approaches to diagnose and treatment. Current diagnostic tools include MRA, CTA, and renal artery duplex ultrasonography. Patients with renal parenchymal disease are poorer candidates for revascularization.