View
2
Download
0
Category
Preview:
Citation preview
고혈압과 azotemia를 동반한
68세 남자 환자
000 (M/68)
Adm : 2002-9-24
Chief complaint
Fatigue Onset) 3 weeks ago
Present illness
- 2년전 고혈압을 진단받았으나 특별한 치료 없이 지내던 환자
로 내원 3주전부터 fatigue, anorexia 발생하여 개인병원 방문
후 creatinine 상승된 소견 관찰되어 전원됨.
Past medical historyDM / HTN / Hepatitis / TB (-/+/-/+) : no medication
Drug Hx (-)
Op Hx (-)
Family historyunremarkable
Personal history
Alcohol (+) : 소주 1병/d weekly
Smoking (+) : 1 pack/d x 40 years
Review of Systems
General : fatigue(+) sweating(-) polydipsia(-) wt loss(-)
H & Neck : headache(-) stiffness(-)
Respiratory : cough(-) sputum(-) dyspnea(-)
Cardiac : chest pain(-) orthopnea(-) palpitation(-)
GI : anorexia(+) nausea(-) vomiting(-) diarrhea(-)
Urinary : dysuria(-) nocturia(-) frequency(-)
Musculoskeletal : numbness(-) pain(-)
Physical Examination
Vital sign: 180/90 mmHg – 78회/min – 20회/min – 36.5 °C
B.W : 62kg Ht. : 172cm BMI 21.0 kg/m2
General appearance
- Alert mentality
- Acute ill-looking appearance
Head & Neck
- No neck vein engorgement
- No palpable cervical mass
Chest- Clear breath sound without crackle or wheezing
- Regular heart beats without murmur
Physical Examination
Abdomen
- Soft and flat abdomen
- Tenderness / Rebound tenderness (-/-)
- No palpable abdominal mass
- Abdominal bruit (+) : Rt
Back & Extremity
- CVA Tenderness (-/-)
- Pretibial pitting edema (-/-)
Neurology
- Motor, sensory : intact
- Babinski (-/-)
Q1. 의심되는 질병은 무엇인가?
Initial Lab Finding (02-9-24)
CBC/DC
8600/mm3 –13.2 g/dl – 38.7 % - 332000/mm³ ( seg. 61.3%)
INR : 1.0 % aPTT : 34.5 sec
Chemistry
T-chol/TG 210/349 mg/dL
TB/DB 0.7/0.1 mg/dL
T-protein/albumin 8.1/4.0 g/dL
AST/ALT 24/26 U/L
ALP/GGT 102/18 U/L
BUN/Cr 31/2.0 mg/dL
Na/K/Cl 135/4.3/96 mmol/L
Ca/P/Mg 9.4/4.4/2.4 mg/dL
CRP <0.5 mg/dL
U/A
RBC 0~1/HPF WBC 0~1/HPF
SG : 1.015 PH : 6.5 protein(-) glucose(-)
Chest X-Ray (02-9-24)
Lab Finding
24hr urine collection
protein 153mg/d
creatinine 1088mg/d
CrCl = 37.8ml/min
ANA 1+, nucleolar
C-ANCA negative
P-ANCA negative
PRA >20 ng/ml/hr (0.8~1.36)
Serum Aldosterone 150 pg/ml (50~194)
Lab Finding
Serologic marker
IgG 1910 mg/dL (694~1618) C3 135 mg/dL (88~201)
IgA 245 mg/dL (68~378) C4 20 mg/dL (15~45)
IgM 194 mg/dL (60~263)
IgE 2200 IU/ml (<100)
ANA(Qual) nucleolar RF < 20 IU/ml (<20)
C-ANCA negative
P-ANCA negative
Anti ds-DNA ab negative
Anti phospho IgM 9.14 MPL/ml (<10)
Anti phospho IgG 4.97 GPL/ml (<10)
Anti Sm-Ab negative
Abdominal US (02-9-25)
Rt kidney : 9.4 cm Lt kidney : 10.9 cm
Renal Doppler US (02-9-26)
Rt kidney Lt kidney
Main a
ITLlower
DTPA Captopril Renal Scan (02-9-27)
Q2. 어떤 치료를 선택할 것인가?
Renal Angiography (02-10-1)
Renal Angiography (02-10-1)
Renal Angiography (02-10-1)
F/U Renal Doppler US (02-11-4)
Rt kidney : 10.5 cm Lt kidney : 10.5 cm
2002-9-26 2002-10-4
Main a
ITLlower
F/U Renal Doppler US (02-10-4)
F/U DTPA Captopril Scan (02-10-4)
Q3. 치료는 과연 종료되었는가?
120
140
180160
150
160170180
7070
100100
80
1009090
0
20
40
60
80
100
120
140
160
180
200
9/24 9/25 9/26 9/27 9/28 9/30 10/2 10/4
SBP
DBP
02-10-1
Angioplasty
9/24 : Cr 2.0 10/2 : Cr 1.9
Clinical Course (1)
Felodipine 5mg
Atenolol 50mg
Irbesartan 75mg
1.41.31.31.2
1.92.0
1.4
0
0.5
1
1.5
2
2.5
3
3.5
4
02-9-24 02-10-2 2002 11
월
2002 12
월
2003 01
월
2003 07
월
2003 11
월 day
Cre
atin
ine
(mg
/dL
)
Cr
Clinical Course (2)
Irbesartan 75mgFelodipine 5mgAtenolol 50mg
Thiazide 12.5mgAspirin 100mg,Atorvastatin 10mg
1.81.7
1.81.71.9
1.51.6
0
0.5
1
1.5
2
2.5
3
3.5
4
2004 03
월
2004 06
월
2004 10
월
2004 12
월
2005 06
월
2005 08
월
2005 11
월 day
Cre
atin
ine
(mg
/dL
)
Cr
Clinical Course (3)
Irbesartan 75mgFelodipine 5mgAtenolol 50mg
Thiazide 12.5 mgAspirin 100mg,Atorvastatin 10mg
F/U Renal Doppler US (06-2-20)
Rt kidney : 7.4 cm Lt kidney : 11.7 cm
F/U Renal Doppler US (06-2-20)
2002-9-26 2002-10-4
Main a
2006-2-20
Clinical Course (4)
2 0 0 6 - 3 2006-11 2 0 0 7 - 1 2 0 0 7 - 8 2007-12 2008-4
Creatinine
(mg/dL)
2.1 1.9 1.9 1.9 2.0 2.04
BP
(mmHg)
1 3 5 / 8 0 1 2 0 / 7 0 1 1 5 / 6 0 1 2 5 / 7 0 1 2 0 / 6 5 135 /75
Irbesartan 75mg
Efonidipine 40mg
Aspirin 100mg EOD
Simvarstatin 20mg
Q4. 이 환자의 혈압과 신기능의 유지에 도움
이 된 주된 치료는 과연 무엇인가?
1. angioplasty
2. intensive medical treatment
3. both
RVHT is an important correctable cause of secondary hypertension.
Cause
Atherosclerosis m/c, older
Fibromuscular dysplasia, uncommon, young aged wemen
Transplant RAS : 10% after KTP, usually in 1 year after surgery
The frequency – variable
< 1 % of mild to moderate elevations in BP
10 to 45 % of acute (even if superimposed upon a preexisting elevation in blood pressure), severe, refractory hypertension
Renovascular hypertension(RVTH)
Pathophysiology of RVHT
Unilateral renal a stenosis Bilateral renal a stenosis
Ang II dependent HTN Volume dependent HTN
Pathophysiology of RVHT
AT II
ACEi,ARBintraglomerular pressure↓
GFR↓
AT II
Angiotensin II
Diagnosis of RVHT : arteriography
Gold standard for Diagnosis
Complications)
Atheroembolism, Contrast induced ARF
But, variety of less invasive tests have
been evaluated for screening purposes.
Vascular studies to evaluate renal a.
MR angiography
Spiral CT
Doppler US
Other studies
Plasma renin activity
Captopril renogram
Diagnosis of RVHT : Doppler Sono
Sensitivity 85~99 % , specificity 92~97 %
Advantage : both anatomic and functional assessment of the renal
a.
Disadvantage
time-consuming , technically difficult, highly operator-dependent
Peak systolic renal artery velocity (Vr)
Vr >180 cm/s
ratio of the Vr / Vaorta ≥ 3.5 Pulsus parvus et tardus
Prolonged AT (> 0.07sec)
RI < usually 0.56 (Normal <0.7)
RI >0.8 : extremely poor outcomes after revascularization
high RI may indicate irreversible intrarenal vascular disease
Diagnosis of RVHT : MR angiography
Sensitivity 100 %, specificity 71 % for 50 ~75 % ASO stenosis
Non-nephrotoxic
Clear image of prox. Renal a, but may miss distal renal a
CIx : claustrophobia , metallic implant, pacemaker or aneurysm clip
GFR<30ml/min : gadolinium nephrogenic systemic fibrosis risk ↑
fibrosis of the skin and connective tissues
prevent bending and extending joints
may cause death
Diagnosis of RVHT : CT angiography
sensitivity and specificity
77 and 94 % for ASO stenosis ≥50 %
28 and 99 % for fibromuscular disease
62 and 90 % for all lesions ≥70 %
sCr > 1.7mg/dL accuracy is lower due to reduced renal blood
flow
Contrast induced ARF
Diagnosis of RVHT : renin activity
Sensitivity 75~100% and specificity 60~95%
In RAS, ↑renin in ischemic kidney, ↓renin in contralateral kidney
Baseline PRA is elevated in only 50 to 80 % in RVHT
1 hour after administration of 25 to 50 mg of captopril
exaggerated increase in PRA.
Lateralizing renal vein renin ratio (affected/contralateral) >1.5
90% predicting value for response to revascularization
But false negative 50~60%, some false positive
need to discontinue antihypertensive medications
Diagnosis of RVHT : Captopril scan
DTPA, hippurate ,MAG3
Oral captopril (25 to 50 mg) is given 1 hour before the isotope is
injected
positive finding
Decreased relative uptake with one kidney < 40 % of total
GFR.
Delayed uptake on affected side
Delayed washout on affected side
Negative finding essentially excludes functionally significant
stenosis
But limited in GFR<20ml/min, bilateral RAS
Goal of Treatment
Improved blood pressure control
Preservation of renal function
Treatment of RVHT
Medical therapy
Revascularization
Percutaneous transluminal renal angioplasty
with or without stent placement
Surgery
Treatment of RVHT : Medical
Antihypertensive drug
ACE inhibitor or an ARB, often in combination with diuretic.
CCB and βB are also effective
Normalization of BP may be associated with reduced renal
perfusion, pressures, and renal function may deteriorate
Control of risk factors for atherosclerosis
Aspirin
Cessation of smoking
antidyslipidemic therapy
In diabetes, glycemic control
Progression of atherosclerotic stenosis may occur in one
third of patients
Treatment of RVHT : revascularization
Indications:
Uncontrolled BP despite maximal therapy
Progressive rise in SCr
Intolerance to ACE-I/ ARB (>30% in SCr or severe
hyperkalemia)
Recurrent pulmonary edema, CHF, or volume overload
Prerequisites:
Experienced operator
Presence of two kidneys
RI < 0.80 in target kidney(s)
Percutaneous transluminal renal angioplasty (PTRA)
Young patients with fibromuscular dysplasia
better outcome than atherosclerosis,
Atherosclerotic lesion: high re-stenosis rates
poor outcome in bilateral RAS
Complication 5~20%
Hematoma, renal artery dissection, renal artery thrombosis or
perforation
Atheroembolic event (maybe irreversible)
ARF d/t radiocontrast agent (maybe reversible)
Stent migration and/or thrombosis
Restenosis 14~18%
Major determinant of risk : vessel size <5mm
Treatment of RVHT : angioplasty
Outcome of therapy
Angioplasty and STent for Renal Artery Lesions (ASTRAL)
750 patients , in the United Kingdom
Changes in BP and renal function during the first year of follow-up are
small, and no major differences requiring study termination
CORAL trial
66 patients with creatinine<2.0
intensive medical therapy VS stent
after 21mo of follow-up, no differences in BP or serum creatinine
Study to evaluate the safety and effectiveness of Palmaz balloon
expandable stent In the REnal artery (ASPIRE-2)
renal artery stenting for failed angioplasty
19.7% major adverse event rate during a 24-mo
In patients with diffuse atherosclerosis, the complication rate with
revascularization is relatively high. Medical therapy may be preferred.
Effect of renal artery revascularization versus
medical treatment alone on clinical outcomes
ASN NephSAP 7(2) March 2008
Revascularization for
atherosclerotic renal artery stenosis
: the treatment of choice?
Recommended