Pitfalls in diagnosing and treating children with renal artery hypertension: author’s reply

Abstract

Sirs, We thank Dr Tullus and co-authors for their interest in our article and their comments [1]. We agree that angiotensin-converting enzyme inhibitors (ACEi) are not the drug of choice in patients with renal artery stenosis because of the danger of a decrease in renal function. However, in patients with hyponatraemic hypertensive syndrome, hypertension is very refractory to treatment, despite multiple antihypertensives, and potent diuretics cannot be used because of the dehydration and electrolyte imbalance. Of course, careful volume repletion with intravenous saline should be done prior to administration of ACEi [2]. Computed tomographic angiography (CTA) is an effective and relatively non-invasive alternative to intra-arterial digital subtraction angiography (DSA) in detecting most cases of renal artery stenosis, especially in centres like ours where DSA is not available and renal artery stenosis common. However, we agree with Dr Tullus that CTA could miss some patients and DSA would still be required if CTA is inconclusive in patients in whom RAS is suspected [3]. Unfortunately, there are no specific serological markers for Takayasu arteritis (TA) [4]. Our patient had a history suggestive of the systemic phase of TA in the form of constitutional symptoms like fever and arthralgia for 3 years prior to presenting to us. He also had an elevated erythrocyte sedimentation rate. These, along with angiographic changes on CTA, prompted us to make the diagnosis of TA in our patient.