Unilateral Renal Parenchymal Disease Research Articles

Nephrectomy for hypertension in pediatric patients with a unilateral poorly functioning kidney: A contemporary cohort

Purpose A unilateral poorly or non-functioning kidney is a cause of hypertension in children. We report the outcomes of pediatric patients with unilateral renal parenchymal disease who underwent nephrectomy for hypertension. Materials and methods Consecutive hypertensive children undergoing nephrectomy with a unilateral poorly or non-functioning kidney were retrospectively reviewed; preoperative and postoperative clinical variables were analyzed. Results From July 2002 to August 2009, 21 patients (8M:13F) with average age 3.5 years and average follow-up 17.8 months were studied. Eleven patients had multicystic dysplastic kidney, 8 had reflux nephropathy, and 2 had ureteropelvic junction obstruction. Fourteen of 21 (67%) had blood pressure normalization after nephrectomy. Seven of 11 with MCDK were normotensive postoperatively compared to 6/8 patients with reflux nephropathy, and 1/2 patients with UPJ obstruction. Of the 14 patients normotensive postoperatively, 7 were on antihypertensives prior to surgery. Four of 7 patients stopped their anti-hypertensive medications postoperatively, 2 decreased from 3 and 4 medications to 1, and 1 remained on an ACE inhibitor. There were 2 patients with contralateral renal scarring, both of which remained hypertensive postoperatively. Conclusions Nephrectomy in hypertensive pediatric patients with a unilateral poorly functioning or non-functioning kidney yielded hypertension resolution in 67% (14/21), permitting cessation or diminution of antihypertensives in many patients. Given the alternative of lifelong antihypertensives with the risk of medication non-compliance and side-effects, nephrectomy is a logical option of care which can be offered to patients and families with informed knowledge of the potential for cure.

447 NEPHRECTOMY FOR HYPERTENSION IN PEDIATRIC PATIENTS WITH UNILATERAL RENAL PARENCHYMAL DISEASE: A CONTEMPORARY COHORT

You have accessJournal of UrologyPediatrics: Congenital Anomalies - Kidney & Ureter1 Apr 2010447 NEPHRECTOMY FOR HYPERTENSION IN PEDIATRIC PATIENTS WITH UNILATERAL RENAL PARENCHYMAL DISEASE: A CONTEMPORARY COHORT Bruce Schlomer, Paul Smith, Theodore Barber, Warren Snodgrass, and Linda Baker Bruce SchlomerBruce Schlomer More articles by this author , Paul SmithPaul Smith More articles by this author , Theodore BarberTheodore Barber More articles by this author , Warren SnodgrassWarren Snodgrass More articles by this author , and Linda BakerLinda Baker More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.519AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES A unilateral poorly functioning or non-functioning kidney is a known cause of hypertension in children. Few small pediatric series have reported on the success of nephrectomy for treating hypertension in these patients, with resolution of hypertension in 50-76%. To expand this experience, we analyzed outcomes of nephrectomy for pediatric patients with hypertension and unilateral renal disease in a contemporary cohort. METHODS This is a retrospective single institution review of consecutive hypertensive patients with unilateral renal parenchymal disease who underwent nephrectomy. Preoperative characteristics such as blood pressure, medications, laboratory values, renal imaging, time of diagnosis, age, and cause of renal disease were tabulated as were postoperative data including blood pressure, medications, complications, laboratory values, and time to normalization of blood pressure. RESULTS Out of 159 nephrectomies from July 2002 to August 2009, 21 met inclusion criteria with follow-up blood pressure measurements. The average age of the patients was 3.5 yrs (range 2.1 mo – 11.8 yrs) and average follow up was 17.8 months (range 1 – 36 months). There were 11 patients with multicystic dysplastic kidney, 9 with reflux nephropathy, and 2 with ureteropelvic junction obstruction. Out of the 21 patients, 14 (67%) were noted to have normalization of their blood pressure postoperatively. Of the patients with MCDK, 7/11 had normal blood pressure postoperatively compared to 6/9 patients with reflux nephropathy, and 1/2 patients with UPJ obstruction. Of the 14 patients with normalization of blood pressure postoperatively, 7 were on antihypertensives prior to surgery. Four of the 7 patients stopped their antihypertensive medications postoperatively, 2 decreased from 3 and 4 medications to 1, and 1 remained on an ACE inhibitor for renal protection. There were 2 patients with contralateral renal scarring, both of which did not have normalization of blood pressure postoperatively. CONCLUSIONS Nephrectomy in pediatric patients with unilateral parenchymal renal disease and hypertension yields resolution of hypertension in 67% of cases, permitting cessation or diminution of antihypertensives in many patients. Given the alternative of life-long antihypertensives with the risk of medication non-compliance and side-effects, nephrectomy is a logical option of care which should be offered to all such patients with informed knowledge of potential for cure. Dallas, TX© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e176-e177 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Bruce Schlomer More articles by this author Paul Smith More articles by this author Theodore Barber More articles by this author Warren Snodgrass More articles by this author Linda Baker More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Efficacy of Nephrectomy for the Treatment of Nephrogenic Hypertension in a Pediatric Population

We evaluated the efficacy of nephrectomy for the management of nephrogenic hypertension in children. We retrospectively reviewed the records of 320 children who underwent nephrectomy between 1991 and 2001, and 22 underwent nephrectomy for the management of hypertension. Of the 22 patients 16 (73%) had long-term followup, including 8 with end stage renal disease who were dialysis dependent, and 8 with normal renal function and unilateral parenchymal renal disease (UPRD). Within the UPRD group 3 patients had renovascular hypertension, 3 had reflux nephropathy, 1 had renal artery thrombosis and 1 had Page kidney. Age at hypertension onset, age at nephrectomy and elapsed time between diagnosis and intervention were studied. Antihypertensive medication requirements before surgery and after postoperative followup were evaluated to assess treatment efficacy. Complete success was defined as blood pressure normalization without antihypertensive requirements. Partial success was defined as decrease in medication requirements and/or discontinuation of minoxidil. Failure of treatment was defined as persistent hypertension, increased medication requirements or minoxidil dependence. In the end stage renal disease group mean age at diagnosis was 5.9 years (range 15 months to 10 years) and bilateral nephrectomy was performed at a mean age of 8.9 years (19 months to 15 years) with average elapsed time between diagnosis of hypertension and nephrectomy of 3 years. After a mean followup of 4.4 years (range 6 months to 8 years) 7 patients (88%) experienced complete or partial success and nephrectomy management failed in 1. In the UPRD group average elapsed time was 2.2 years (range 1 month to 10 years) between a mean age at diagnosis of 6.7 years (birth to 16 years) and a mean age at nephrectomy of 8.9 years (1 month to 17 years). After a mean followup of 1.6 years (range 1 month to 5 years) complete or partial success was experienced by all 8 patients (100%). All 8 UPRD group patients experienced adequate residual renal function. The vast majority of patients in both categories experienced complete or partial success from nephrectomy for the management of medication refractory hypertension. Nephrectomy for hypertension control is safe and effective, and obviates the need for morbid medications. We continue to accrue patients in a prospective manner.

Nephrectomy in children for hypertension associated with unilateral renal parenchymal disease

Seven children with unilateral renal parenchymal disease underwent nephrectomy for hypertension; 3 were cured, 2 were ameliorated, and 2 were unchanged. The literature is reviewed, and the diagnostic parameters are discussed. We conclude that nephrectomy remains a viable therapeutic alternative to medical management, but the outcome in any particular individual is unpredictable.

Frequent Falsely Negative Renal Vein Renin Tests in Unilateral Renal Parenchymal Disease

A retrospective analysis of 12 hypertensive patients with unilateral renal parenchymal disease was done to evaluate the roles of renal vein renin testing and an operation. The patients were considered to have renal parenchymal disease on the basis of radiographic and/or pathologic findings. Only 2 patients had positive renal vein renin studies. Both of these patients were improved after unilateral nephrectomy but 1 had subsequent progression of disease and renal failure. Of the 10 patients with negative studies 5 had unilateral nephrectomy: 4 of them, nevertheless, experienced substantial improvement in the hypertension.It is concluded that hypertensive patients with unilateral renal parenchymal disease often can benefit from an operation and that renal vein renin testing in such patients can be misleading.

Diazoxide-induced renin release in diagnosis of remediable renovascular hypertension.

In hypertensive patients with unilateral renal artery stenosis, intravenous diazoide increased renal vein renin activity more on the involved side than on the contralateral side, whereas, in a group with predominantly unilateral renal parenchymal disease, the increase in renal vein was similar for both kidneys. In patients with bilateral renal artery stenosis, the use of diazoxide was helpful in lateralizing the dominant ischaemic lesion. Diazoide administration appears to be a safe, rapid and convenient method of increasing the sensitivity of the renal vein renin test used in predicting the outcome of surgical treatment of renovascular hypertension. Bilateral renal vein renin determination of established value in the diagnosis of functional renal ischaemia. 1-4 However, in the use of this procedure to predict the efficacy of corrective surgery, false positive and false negative results still occur. Thus, various manoeuvres which stimulate renin release have been employed to improve the sensitivity of the test. 5-7 We report a new application the practical approach to of this procedure in the diagnosis of renal hypertension, which both basal and stimulated levels of renal venous renin activitity can be measured during a brief period of bilateral renal vein catherization.

Task force V: Hypertension

The Task Force recommends that: 1. 1. There be no changes in the present regulations regarding limits of blood pressure that are acceptable for flying status. 2. 2. The serum cholesterol and glucose concentrations and cigarette-smoking habits be included in the equation with blood pressure in determining health criteria for flying status. 3. 3. Thiazide compounds and related diuretic agents be officially approved for use by pilots and crew members without further testing. 4. 4. The FAA initiate plans to support research to determine the effect of other antihypertensive drugs on pilot performance under controlled conditions with hypertensive pilots as subjects and using treadmill exercise, the human centrifuge, simulators, the altitude chamber and specific physiologic and psychologic testing methods already perfected. 5. 5. A hypertensive pilot whose blood pressure can be controlled with medications acceptable from the standpoint of flying safety and who has no evidence of target organ disease be granted a waiver to fly so long as his blood pressure is maintained within the limits prescribed by present regulations. 6. 6. The following evidence of target organ disease should be disqualifying regardless of the level of blood pressure or the ability to control hypertension with medication: (a) left ventricular hypertrophy as manifested in the electrocardiogram by voltage changes andST-T abnormalities (voltage changes alone should not be disqualifying); (b) roentgenographic evidence of cardiomegaly (greater than 20 percent); (c) azotemia (serum creatinine greater than 2.0 mg/100 ml); (d) hypertensive retinopathy of Group 3 or 4 (Keith-Wage-ner-Barker classification). 7. 7. A pilot or crew member who has normal blood pressure 3 or more months after successful operation for pheochromocytoma, primary aldosteronism, renovascular disease or unilateral renal parenchymal disease, and who shows no evidence of target organ disease or adrenal insufficiency, be permitted to fly. If residual hypertension is present and can be controlled with acceptable drugs, and there is no target organ disease, permission to fly should be granted on the same basis as for persons with essential hypertension. 8. 8. A pilot who has had surgical treatment for Cushing's syndrome or lumbodorsal sympathectomy for hypertension not be permitted to fly, even if he is normotensive as a result of the operation. 9. 9. A pilot treated with acceptable antihypertensive agents be permitted to return to duty when the blood pressure is within specified limits (Table I) and he has been free of undesirable side effects for 3 consecutive weeks, the blood pressure having been recorded at weekly intervals. 10. 10. A pilot who is taking antihypertensive medication have his blood pressure measured at least once every 3 months in the supine or the seated position and in the standing position after 3 minutes, and the examining physician file a signed report of the reading in the pilot's medical file in the regional FAA medical office after each visit. More than 75 percent of the readings must be equal to or less than the upper limit prescribed in present regulations and none more than 10 percent above this level if the pilot is to be permitted to continue to fly with a waiver. 11. 11. A pilot whose blood pressure exceeds 140 mm Hg systolic or 90 diastolic, or both, be required to have his blood pressure measured every 6 months and the results entered in his medical file, even though he may choose not to take medication because his blood pressure is within acceptable limits according to current FAA regulations.

Hypertension and unilateral parenchymal renal disease. Evidence for abnormal vasoconstriction-volume interaction

Hypertension was not renin-dependent in the majority of 62 hypertensive patients with seemingly unilateral renal parenchymal disease, as indicated by plasma renin activity: low in 14 (23%), normal in 40 (56%), and high in only 8 (13%). By a weighted scoring system for analysis of differential renal-vein and peripheral renin levels, 70% (16 of 23) of these patients did not give scores predictive of cure by nephrectomy. Thus, occult bilateral disease reflected by attendant volume expansion and consequent reactive renin suppression may explain the well-known disappointing cure rate after uninephrectomy in this group. Since unilateral hypersecretion of renin with a completely normal contralateral kidney is rare in this group, abnormal renal-vein and peripheral renin values should be a prerequisite for advising nephrectomy, especially when the suspected kidney shows considerable excretory function. (<i>JAMA</i>233:1177-1183, 1975)

Hypertension and Unilateral Parenchymal Renal Disease

Hypertension was not renin-dependent in the majority of 62 hypertensive patients with seemingly unilateral renal parenchymal disease, as indicated by plasma renin activity: low in 14 (23%), normal in 40 (56%), and high in only 8 (13%). By a weighted scoring system for analysis of differential renal-vein and peripheral renin levels, 70% (16 of 23) of these patients did not give scores predictive of cure by nephrectomy. Thus, occult bilateral disease reflected by attendant volume expansion and consequent reactive renin suppression may explain the well-known disappointing cure rate after uninephrectomy in this group. Since unilateral hypersecretion of renin with a completely normal contralateral kidney is rare in this group, abnormal renal-vein and peripheral renin values should be a prerequisite for advising nephrectomy, especially when the suspected kidney shows considerable excretory function.

Angiotensin II plasma levels in hypertensive patients.

Abstract The response of peripheral venous plasma angiotensin II (A‐II) to upright posture combined with an injection of furosemide was higher in patients with hypertension and associated renal parenchymal disease, renal artery stenosis or malignant hypertension than in patients with essential hypertension and normotensive control patients. Very low responses to the same stimuli were observed in primary aldosteronism. Markedly increased A‐II levels were measured in the renal veins of the affected kidneys in hypertensive patients with associated unilateral renal parenchymal disease or renal artery stenosis, suggesting that human kidneys contain considerable converting enzyme activity. Plasma A‐II levels were normalized in three patients with primary aldosteronism after removal of an adrenal adenoma and in one patient with malignant hypertension after bilateral nephrectomy and renal transplantation.

Peripheral and renal venous plasma renin concentration in hypertensive patients with unilateral renal or renovascular disease.

Renal venous catheterization was carried out in a consecutive series of 32 hypertensive patients with unilateral renal or renovascular disease. Plasma renin concentration (PRC) was measured in systemic and renal venous blood with a method allowing the expression of results in terms of Goldblatt Units. Blood samples were collected before and after intravenous injection of furosemide (0.33–0.66 mg/kg body weight).Systemic PRC was elevated in ten out of 19 patients with lesions of the main renal artery. Only one out of 11 patients with unilateral parenchymal renal disease had elevated systemic PRC. A unilateral significant veno-arterial renin concentration difference over the affected kidney was found in eight out of 15 patients with renal artery stenosis and in three, out of 11 patients with unilateral parenchymal renal disease. In patients with renal artery stenosis, a close association was found between increased systemic PRC and renal venous PRC-ratios <1.8. Furosemide led to an increased release of reni...

Results of nephrectomy in hypertension associated with unilateral renal disease.

Nephrectomy has been carried out in 34 patients with hypertension associated with unilateral parenchymal renal disease (28 with unilateral pyelonephritis, 3 tuberculosis, 2 hypoplasia, and 1 adenocarcinoma). In 13 of the patients the blood pressure was corrected, in four it was improved, and in 17 it was unaffected. The intravenous pyelogram (by the infusion technique with nephrotomography if necessary) and renogram give adequate information in most patients with unilateral parenchymal renal disease but may need to be supplemented by aortography, or retrograde pyelography, or divided renal function studies in a few special circumstances. When the function of the damaged kidney is less than 25% of the total (which is well maintained), and the contralateral kidney is intact, nephrectomy is recommended provided the hypertension is significant; success is more likely in younger patients with a short history of hypertension.

OCCULT PRIMARY RENAL DISEASE IN THE HYPERTENSIVE PATIENT.

<h3>Introduction</h3> Since Goldblatt's original description of the production of hypertension by partial constriction of the renal artery of dogs in 1934,¹there has been increasing interest in the relationship of the kidney to human hypertension. Clinical interest was originally confined largely to parenchymal renal disease, especially unilateral pyelonephritis, hydronephrosis, and the atrophic kidney. A large number of hypertensive patients with unilateral parenchymal renal disease were subjected to nephrectomy. Enthusiasm for this procedure, though initially high, was dampened considerably by Homer Smith's reviews of the results in 1943²and again in 1956.³In the latter report, only 26% of 575 unilateral nephrectomies had resulted in cure of hypertension. During the past five years, due largely to advances in vascular reconstructive surgery, increasing attention has been directed towards renovascular disease. Here, the results of surgery have been considerably better. In carefully selected patients there has been a 40% to

The influence of glomerular filtration rate, solute excretion and hydration on the concentrating mechanism of the experimentally diseased kidney in the dog.

Recent studies from this laboratory indicate that the concentrating ability of the diseased kidney in the dog is not markedly impaired when the contralateral kidney is intact and the internal environment remains essentially normal ( 1 ). These data suggested that the direct effects of the pathological processes on the structural integrity of the functioning nephrons did not render the concentrating mechanism impotent. The present studies represent an attempt to obtain additional information about the functional characteristics of the concentrating mechanism in the dog with experimentally induced renal disease. The majority of experiments have been performed on animals with one of several types of unilateral renal parenchymal disease. In addition, observations have been made on dogs with unilateral hemiinfarcted kidneys and with bilateral renal parenchymal disease.