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報告者: fellow 1 陳筱惠 指導醫師:陳冠興醫師 Commented by CV1 張其任醫師

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Text of 報告者: fellow 1 陳筱惠 指導醫師:陳冠興醫師 Commented by CV1 張其任醫師

  • fellow 1 Commented by CV1

  • Name: OSex: femaleAge: 90-year-oldChart number: 487733Date of admission: 2011/11/18

  • Persistent dizziness for 1 day

  • Underlying diseases: chronic kidney disease (stage 4), congestive heart failure, and atrial fibrillation Dizziness with bradycardia episode at home (HR around 40bpm)Associated S/S: no palpitation, chest pain, cold sweating, or consciousness disturbanceAt ER: clear consiousness, af SVR

  • Hypertension (BP when OPD follow-up: 180~/70~mmHg)Heart failure, LVEF:68%, HCVD related, atrial fibrillation rhythmChronic kidney disease, stage 4, eGFR: 29.4ml/min, 2011/04/24 crea: 1.64mg/dlObstrutive sleep apnea syndrome with restrictive lungAsthma historyOther significant systemic diseases: denied

  • Doxazosin 4mg 1# bidIsosorbide-5-mononitrate cr 60mg 1# qdFurosemide 40ng 0.5# qdAliskiren 150mg 1# qd 2011/06/28~Exforge (Amlodipine 5mg + Valsartan 80mg) 1# bid 2011/11/15~Micardis Plus (Telmisartan 40mg + HCTZ 12.5mg) 1# qd 2011/10/18~2011/11/15Telmisartan 40mg

  • Allergy: no known allergyAlcohol: denied; betel-nut: denied; cigarette: deniedOver-the-counter medication or chinese herb: nil

  • No family history of malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases

  • Vital signs: blood pressure: 135/58mmHg; temperature: 36.5C; pulse rate: 44/min; respiratory rate: 18/minGeneral appearance: acute ill lookingEye: conjunctiva: pale, sclera: no ictericNeck: supple, no lymphadenopathy or jugular vein engorgement Chest: symmetric expansion breathing sound: bilateral clear heart sound: irregular heart beats, no S3 or S4, no murmursAbdomen: soft, flat, no tenderness, muscle guarding, or rebounding liver/spleen: impalpable bowel sound: normoactiveExtremities: no lower limb pitting edemaSkin: intact, no rash

  • WBC6.2x1000/ulHgb8.3 g/dlHct25.4 %MCV87 fLPLT159 x1000/uLSegment78.9 %

    BUN118.1 mg/dLCreatinine4.43 mg/dlGPT9 IU/LNa134 mEq/LK8.2 mEq/LCa8.2 mg/dLMg2.3 mEq/LTropo - I

  • Atrial fibrillation with slow ventricular rate, suspect hyperkalemia inducedAcute on chronic kidney disease, favor ARB drug effect, complicated with hyperkalemia and azotemiaHypertension, poorly controlledHeart failure, LVEF:68%, HCVD related, atrial fibrillation rhythmObstrutive sleep apnea syndrome with restrictive lungAsthma history

  • H/D

    U/O2020660740860BW55.4654.855.956.6BUN118.158.8Crea4.432.65Na134138K8.55.1CaPC0221.3

    189/88mmHg141/72mmHg149/70mmHg165/79mmHg

  • Kidney echo

    U/O23016302450350920BW69.559.158.3BUN68.773Crea2.822.45Na125123K4.75.0Ca8.38.0P4.84.5C02

    190/99mmHg159/72mmHg186/84mmHg206/94mmHg186/89mmHg

  • Cortisol 14.1Renin 1644Aldosterone 328TSH 0.77Free T4 26.939

    U/O900820400810710BW57.957.259.560.7BUN5151.4Crea1.872.63Na127123K4.54.2Ca8.27.7P2.73.0C02

    201/96mmHg181/80mmHg145/66mmHg179/86mmHg156/72mmHg

  • U/O4001210700300400BW61.661.161.362.4BUN58.763.372.8Crea2.592.313.12Na123125126K4.95.35.6Ca8.08.0P4.75.5C0215.417.3

    194/87mmHg172/79mmHg172/69mmHg151/70mmHg209/86mmHg

  • Renin 995

    U/O13202500600300950BW61.660626263.1BUN80.4Crea2.65Na128K4.8Ca8.2P6.0C0221.1

    179/82mmHg156/76mmHg174/84mmHg169/82mmHg176/75mmHg

  • H/D

    U/O21801400650200600BW61.8BUN80.747Crea3.012.08Na123130K3.93.8Ca7.98.7P5.12.7C02

    188/84mmHg193/85mmHg192/78mmHg201/95mmHg210/85mmHg

  • U/O45070030013090BW58.2BUN58.1Crea3.12Na127K4.1Ca8.4P4.3C0222.5

    203/90mmHg191/83mmHg204/90mmHg174/75mmHg172/95mmHg

  • Hickman implantation

    U/O100801502300BW58.7BUN47.3Crea4.78Na127K4.9Ca7.9P3.6C0224.9

    177/81mmHg178/96mmHg196/89mmHg179/88mmHg202/89mmHg

  • Renal angiography

    U/O0750650500600BW54.9BUN37.5Crea4.83Na134K4.3Ca8.0P4.6C0223.7

    168/74mmHg164/87mmHg163/69mmHg141/74mmHg168/76mmHg

  • Hold H/D

    U/O1100110022501300950BWBUN37.944.5Crea4.924.57Na131131K4.44.5Ca7.88.5P4.95.4C0223.422.6

    197/85mmHg151/69mmHg168/79mmHg122/61mmHg161/74mmHg

  • 1/17 remove hickman

    U/O14501400BW50.2BUN36.519.6Crea2.831.74Na133136K4.45.0Ca9.08.6P4.24.0C02

    147/81mmHg134/64mmHg119/54mmHg

  • Renal Artery Stenosis: Optimizing Diagnosis and TreatmentProgress in Cardiovascular Diseases 54 (2011) 2935

  • 1st: atherosclerotic lesions, 90% of all renovascular lesionsTypically in older individualsAn equal prevalence in men and womenPredominantly at or near the origin of the renal artery and usually are associated with aortic diseaseMay present with hypertension or renal insufficiency

  • 2nd: fibromuscular dysplasia (FMD)More often in young womenUsually associated with hypertension without renal insufficiency

  • A limited literature addresses the clinical factors that are predictive of finding atherosclerotic RAS and that may be useful in guiding appropriate screening.

  • Doppler ultrasoundComputed tomography angiography (CTA) and magnetic resonance angiography (MRA)Conventional angiographyImaging For Renovascular DiseaseSeminars in Nephrology, Vol 31, No 3, May 2011, pp 272-282

  • Duplex ultrasonography: screening testSensitivity: 92.5% to 98%; specificity: 96% to 98%NontoxicNo exposure to ionizing radiationCapable and reliableMajor limitation: dependence on technician skill for acquisition of adequate images; others: obesity, bowel gas, and recent food intake

  • Computed tomography angiography (CTA):Sensitivity and specificity: > 95%Multicenter Renal Artery Diagnostic Imaging Study in Hypertension (RADISH) study SEN 64%, SPE 93%QualitativeRisk of contrast nephropathy

  • Magnetic resonance angiography (MRA):Slightly lower sensitivities and specificities than CTA; RADISH study SEN 62%, SPE 84%To measure flow, renal perfusion, and renal functionPoorer spatial resolution, limited availability, patient tolerance, and the need for extended breath-holdingNephrogenic sclerosing fibrosis associated with Gadolinium in patients with renal insufficiency

  • Duplex ultrasonography is inferior to MRA and CTA.

    Diagnostic tests for renal artery stenosis in patients suspected of having renovascular hypertension: a meta-analysis. Ann Intern Med 2001;135:401-411.

  • Captopril renography:Poor screening testDependent on comparative imaging of the right and left kidneysThe incidence of bilateral RAS is approximately 30%.May be useful when trying to determine the physiologic significance of a known intermediate stenosis

  • Invasive angiography: gold standardConfirm the diagnosis based on prior noninvasive testing and with the intent to perform an interventionThe most commonly used methodology: intra-arterial digital subtraction angiographyComplications: related to the vascular access, placement of the guidecatheter into the renal artery, balloon and stent deployment, and contrast administration

  • Carbon dioxide (CO2)Image quality is reduced.May create greater uncertainty about lesion severity unless combined with judicious use of iodinated contrast

  • Medical therapyRevascularization: balloon angioplasty +- stenting or Surgical bypass or reconstructionGoals:Blood pressure controlTreatment of heart failure and/or pulmonary edemaPrevention of nephropathy

  • Medical therapyLifestyle interventions:Dietary recommendations in atherosclerotic RAS:Increased intake of fruits and vegetables, dietary calcium through low fat dairy products

  • Angiotensin-converting enzyme (ACE) inhibitorsPotential to induce acute hemodynamically mediated renal failure in patients with RASLower cardiovascular event rates (10% vs 13%) and need for dialysis (1.5% vs 2.5%)The cost of an increased risk of hospitalization for acute renal failure (1.2 vs 0.6%)Selection bias: patients with better renal function and/or less severe disease are treated with these agents resulting in an apparent improvement of outcome

  • Other agents used to control the atherosclerotic process are important for the care of patients with atherosclerotic RAS.Statins: decrease death, limit lesion progression, and promote restenosis-free survivalPlatelet inhibitors: prevention of future cardiovascular events

  • Revascularization:Balloon angioplasty +- stenting:Lesion severity, renal function, the skill level of the operators, and complication ratesSurgical bypass or reconstruction:Not benefit over angioplastyHigh rates of adverse outcomes with surgery, including perioperative mortality of approximately 10%

  • When stenting is performed, there are a number of technical factors that should be considered as part of the procedure.No touch technique for engaging a catheter into the renal artery reduce the risk of atheroembolismNo embolic protection device is approved by the Food and Drug Administration for use in the renal artery.Abciximab (a platelet glycoprotein IIbIIIa inhibitor) ??

  • A cure of hypertension with revascularization< 10% in patients with atherosclerotic RASApproximately 50% in patients with FMDYounger patients more likely to achieve this outcome.Consistent and sustained blood pressurelowering effect of revascularization

  • Considerable controversy exists regarding the use of revascularization of atherosclerotic RAS to treat or prevent the development of ischemic nephropathy.Stent revascularization in patients with ischemic nephropathy and significant stenoses resulted in a slower rate of progression of nephropathy.In a minority of patients, an actual

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