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6/9/2012

Renal vascular disease

Definition: diseases that involved the renal vascular system and affecting renal blood supply which may lead to renal ischaemia,with subsequent acute or chronic kidney disease .and or secondary hypertension.

Dis of intrarenal vessels

HU syndrome
TTP
DIC
Malignant hypertension
Small-vessel vasculitis
Systemic sclerosis .
('cholesterol' emboli).
Large-vessel disease
renal artery stenosis.


Acute occlusion
Gradual narrowing

Acute renal artery occlusion

is an important and potentially reversible cause of renal failure.
Early recognition and appropriate treatment can prevent permanent loss of renal function.

Condition associated with renal artery occlusion.

Abdominal trauma or surgery.
Embolism (from heart ).
Hypercoagulable states.
Dissecting abdominal aortic or renal aneurysm Vasculitis (polyarteritis nodosa, Kawasaki disease, Takayasu's arteritis) .
Abdominal aorta surgeryDuring coronary angiography.

Clinical features

lumbar or flank pain.
nausea.
vomiting.
fever.
Hematurea.
It is frequently associated with acute onset of hypertension owing to the activation of the renin-angiotensin system.
Renal failure ??


Laboratory tests
leukocytosis
increased levels of serum aspartate aminotransferase, lactate dehydrogenase, and alkaline phosphatase. .
Microscopic hematuria may also be seen.
Significant renal dysfunction may be associated with bilateral renal infarction or infarction of a solitary functioning kidney.

Other test:

and duplex Doppler studies .
computed tomography or magnetic resonance angiography have shown improved diagnostic accuracy.
to establish the diagnosis of renal vascular occlusive disease. Radionuclide imaging with technetium-labeled diethylenetriaminepentaacetic acid or dimercaptosuccinic acid will show no blood flow to
However, the diagnosis is more reliably established by renal arteriography.

Treatment:

Therapeutic options include anticoagulation,.
intravenous or intra-arterial thrombolytic therapy,.
percutaneous angioplasty, clot extraction .
surgical thrombectomy.

Renal artery stenosis:

reduction of renal blood flow is associated with > 70%.
Aetiology:
Fibro muscular hyperplasia.
Atherosclerosis.
vasculitis, (Takayasu's arteritis ,polyarteritis nodosa).


Atherosclerosis
Site (it is an ostial stenosis ).
Its the common cause, in older patients.
associated with atherosclerosis within the aorta ,and other vessels .
many patients die from coronary, cerebral or other vascular disease rather than renal failure.
As may cause renal failure (ischaemic nephropathy).

fibromuscular dysplasia

. it is uncommon congenital disorder of unknown cause affecting the media ('medial fibroplasia'), which narrows the artery but rarely leads to total occlusion
Site.
Age (< 50 years).
Sex. F > M .
It most commonly presents with hypertension in patients aged 15-30 years.
It may be associated with disease in other arteries; for example, carotid artery dissections .

Clinical features:

hypertension.
Renal impairment.

When one should suspect RAS:

severe, uncontrolled hypertension .
Both kidneys are asymmetrical in their size .
Hypertensive patient with Recurrent attack of pulmonary oedema .
Hypertension with peripheral vascular disease of lower limbs .
Raised urea and creatinine after introduction of ACE inhibitors ) A drop in GFR of > 20%, or a > 25% rise in creatinine(


Investigations  Blood urea and serum creatinine.
serum K may be low?? (high BP &low K)
Ultrasound
may reveal a discrepancy in size between the two kidneys.(small size kidney).
Vascular imaging is required to diagnose renovascular disease.

Angiogram or MRIA.

in patients in whom intervention to improve renal perfusion
young patients and those in whom blood pressure cannot be controlled with antihypertensive agents ('resistant hypertension'),
those who have a history of 'flash' pulmonary oedema .
accelerated phase ('malignant') hypertension.
those in whom renal function is deteriorating.

Management:

Angioplasty complication:
contrast nephropathy .
renal artery occlusion and renal infarction.
and atheroemboli from manipulations in a severely diseased aorta.
Small-vessel disease distal to the stenosis may preclude substantial functional recovery.
Surgical intervention is rarely undertaken now for atherosclerotic disease, as it is associated with high morbidity and mortality.
medical management with blood pressure-lowering, low-dose aspirin and lipid-lowering drugs; this should usually have been attempted before angiography is performed.
angioplasty, with placement of stents in atherosclerotic disease areas to improve primary patency rates and prevent rapid recurrence.


Small vessels disease.
Bilateral invovement, associated with systemic disorder result in renal impairment.
HUS.
TTP
DIC.
Malignant hupertension.

HUS .TTP

microangiopathy .
thrombocytopenia.
The clinical features of and therapy for these disorders are similar, although some differences exist
Renal involvement is more common in HUS .
Both disorders may be associated with
malignancy,
oral contraceptives,
antineoplastic agents,
infections,
autoimmune diseases.


Management

The rate of spontaneous recovery of HUS is high in children, and only supportive therapy may be required
The prognosis in adults is less favorable, and additional therapy is usually necessary. Plasma exchange is the most effective modality, with a good response in up to 90% of cases.
Vinacritine,steroid,splenectomy









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