RAPID PROGRESSION FROM UNILATERAL TO BILATERAL RENAL ARTERY STENOSIS (RAS) IN A PATIENT WITH FLASH PULMONARY OEDEMA, HYPERTENSIVE ENCEPHALOPATHY AND RENAL SHUT-DOWN

Abstract

Objective: Atherosclerotic renal artery stenosis (RAS) affects the most proximal portion of the renal artery and approximately 20% of patients have bilateral RAS. We describe an elderly patient with unilateral RAS, post renal artery angioplasty presenting with resistant hypertension, hypertensive encephalopathy, flash pulmonary oedema and renal shutdown after progressing to bilateral RAS kidneys. Design and method: We present a case of 71 year old Indian women with known history of hypertension secondary to right renal artery stenosis underwent right renal artery stenting in March 2016, who was admitted in April 2018 with hypertensive urgency. Results: Ultrasound Doppler of renal artery showed more than 50% stenosis with stent hyperplasia throughout length of the stented right renal artery. There was no evidence of RAS on the left side on ultrasound Doppler. Right renal artery angioplasty was done in view of poorly controlled hypertension with systolic blood pressure ranging between 190 to 230mmHg. During right renal angioplasty, there was incidental finding 50–60% stenosis of the left renal artery. Day 2 post stenting, patient's systolic blood pressure rose to 220 mmHg and started complaining of bi-frontal headache and vomiting. Computed tomography of the brain revealed subtle vasogenic oedema in bilateral frontal lobes likely posterior reversible encephalopathy syndrome (PRES). The patient clinically deteriorated with worsening renal function (creatinine value: 440mmol/L from a baseline of 64mmol/L), metabolic acidosis, oliguria, acute pulmonary oedema and high blood pressure requiring eight (including diuretics) anti-hypertensive. Hemodialysis was initiated and urgent CT angiogram was done to evaluate left renal artery which showed 90% left renal artery stenosis and stented subsequently. Post left renal artery stenosis, patient's blood pressure stabilised and the number of anti- hypertensive were reduced to 5 types. The patient's renal function normalised (creatinine value: 72mmol/L) and recovered from acute pulmonary oedema. Conclusions: In a patient with unilateral RAS post stenting presenting with resistant hypertension, it is important to rule out stent thrombosis versus progression to bilateral RAS and rapid reversal with revascularization is crucial in order to prevent cardiovascular and renal complications, reduce the mortality and morbidity and restore the renal function.