Apport de la scintigraphie rénale avec test au captopril dans l’exploration de l’hypertension artérielle rénovasculaire : à propos d’un cas

IntroductionDynamic renal scintigraphy with ^99mTc-DTPA and captopril test is a non-invasive functional method for the diagnosis of renovascular hypertension. It allows differentiating between hypertension induced by renal arterial stenosis from primary arterial hypertension with an incidental stenosis.Case reportA 14-year-old girl, without previous medical history, developed a severe arterial hypertension with cephalgias and ears buzzing. Auscultation revealed a murmur in the left lumbar pit. Renal angiography objectified a stenosis of the infrarenal aorta due to a circumferential parietal thickening associated to renal arteries stenosis more marked in the left side. Dynamic renal scintigraphy after administration of captopril highlighted a marked collapse of the rate of tracer uptake exceeding 40% on the left side with an increase in the time of collecting on the right side testifying a frankly positive test prevailing on the left. A transluminal angioplasty of the left renal artery and a revascularisation surgery on the right side were carried out. The evolution was marked by an improvement of blood pressure figures.DiscussionDynamic renal scintigraphy using ^99mTc-DTPA with captopril test constitutes a non-invasive process with a low dosimetry for the patients. Its principal goal is to affirm the role of renovascular stenosis in the origin of arterial hypertension and to determine which hypertensive patients with renal arterial stenosis can be treated successfully by surgical or endoscopic revascularisation of the kidney.     

Magnetic resonance tomography in the diagnosis of renovascular hypertension]

MR tomography was used for investigation of 38 patients with renovascular hypertension (RVH) and 26 healthy persons. A possibility of the use and practical value of the method in the diagnosis and evaluation of renal function and renal arteries (RA) were under study. Some quantitative MRT indices were calculated both for the patients and healthy persons. They included spin-spin relaxation time, proton density, and signal intensity. These data can provide important information on renal function in RVH with relation to kidney sizes and the state of the renal parenchyma (evaluation of the cortical substance and medulla and the border between them). In some cases MRT ensures noninvasive diagnosis of PA stenosis.     

The Role of Radioisotope Renal Scanning in the Assessment of Renal Disease

Experience with 500 radio-chlormerodrin renal scans has shown that the technique can detect (1) altered renal function, both focal and generalized, (2) space-occupying kidney lesions, and (3) renal size and disease in some cases in which the blood urea nitrogen is elevated and the excretory urogram inconclusive.The technique is valuable as an adjunct to the intravenous pyelogram since it may discriminate more disease than was thought to be present or may distinguish between anomalous variations in renal outline and calyceal displacement from parenchymal disease. The technique is completely harmless and there are no known contraindications to the test agent, radio-chlormerodrin.     

Renal extraction of circulating adiponectin in patients with renovascular hypertension

BACKGROUND: Patients with chronic renal failure are characterized by an elevated plasma adiponectin concentration, which is significantly lowered after successful kidney transplantation. The direct renal clearance and extraction of adiponectin have not yet been documented in humans. Therefore the aim of the study was to estimate separate kidney extraction of adiponectin, by measuring its concentration in the aorta and both renal veins, in patients with renovascular hypertension caused by unilateral renal artery stenosis. METHODS: In 30 patients with significant (> 70%) unilateral renal artery stenosis, plasma adiponectin was measured in blood samples taken from the aorta, both renal veins and the vena cava inferior below the orifices of the renal veins. RESULTS: Renal venous plasma adiponectin concentrations (both from the kidney with renal artery stenosis and from the contralateral organ) were only numerically lower than the concentrations measured in the aorta (11.10 [8.65-13.56]; 11.12 [8.81-13.42]; 11.35 [8.90-13.80] microg/ml, respectively). Fractional extraction of adiponectin was 5.0 [-1.6-11.0]% in the kidney with renal artery stenosis and 3.0 [-2.4-9.01% in the contralateral "normal" kidney. Slightly higher concentrations of plasma adiponectin were observed in the vena cava inferior below the orifices of the renal veins (11.79 [9.14-14.44] microg/ml). In patients with unilateral renal artery stenosis significant negative correlations were found between plasma adiponectin concentration obtained from the vena cava inferior below the orifices of renal veins and eGFR (r = -0.38; p < 0.05), systolic (r = -0.71; p < 0.0001) and diastolic blood pressure (r = -0.40; p < 0.04), as well as serum triglyceride concentrations (r = -0.64; p < 0.001). CONCLUSION: The findings indicate that the fractional renal extraction of adiponectin is rather low.     

Renal vein plasma adenosine 3',5'-cyclic monophosphate in renovascular hypertension.

The concentration of plasma adenosine 3'',5''-cyclic monophosphate (cyclic AMP) and plasma renin activity (PRA) were measured concomitantly in blood from both renal veins and in arterial blood in 22 hypertensive patients. In the nine patients with true renovascular hypertension the concentration of plasma cyclic AMP was greater in the venous effluent of the kidney affected by the renal artery stenosis than in that of the unaffected or less affected kidney. The arteriovenous difference in cyclic AMP concentration was less on the affected side in all but one patient. The arteriovenous differences in PRA identified the affected kidney as the source of hyper-reninemia and showed that renin release from the other kidney was suppressed. In the 13 patients with hypertension associated with but unrelated to renal artery stenosis there were no consistent patterns of cyclic AMP concentration or PRA in the venous effluent of the kidneys or of their arteriovenous differences. In renovascular hypertension the venous effluent of the kidney affected by renal artery stenosis contains not only more renin but also more cyclic AMP, owing to either increased cyclic AMP production or decreased excretion or extraction of cyclic AMP by the affected kidney. This unilateral increase in cyclic AMP concentration may become a complementary diagnostic feature of true renovascular hypertension.     

Pheochromocytoma presenting with pulmonary edema and hyperamylasemia.

A 28-year-old woman was admitted to hospital with acute pulmonary edema, mild abdominal discomfort and hyperamylasemia. From the 2nd hospital day hypertensive episodes occurred daily. The furosemide screening test for renovascular hypertension revealed elevated plasma renin activity (PRA) but an intravenous pyelogram revealed a right suprarenal mass and no evidence of renovascular compression. Elevated values of plasma and urinary catecholamines indicated a pheochromocytoma, and a single chromaffin tumour was resected. It is important to monitor left ventricular filling pressure during operative removal of a pheochromocytoma. Postoperatively the patient had normal blood pressure and PRA. Decreased urinary amylase clearance and abnormal pancreatic and salivary amylase isoenzymes were found.     

Reconstructive vascular surgery for renovascular hypertension

Forty-six patients who underwent renal artery repair for presumptive renovascular hypertension are presented. Preoperative investigation included a rapid sequence IVP, a high quality angiogram and split function studies, as well as renin assays of renal venous blood in the more recent cases. Atherosclerosis was the causative pathological lesion in 60% of the patients, with fibromuscular dysplasia or miscellaneous causes of stenosis accounting for the remaining 40%.Surgical correction was usually obtained by bypass grafting (57%). Hypertension was cured or significantly improved in 36 patients (78%).Optimal results are dependent upon complete preoperative investigation and surgical repair of all the stenotic areas.     

RENOGRAMS—Correlation with Renal Arteriography and Intravenous Pyelography

A study was carried out to determine how well the information supplied by a radioactive renogram correlates with that obtained by renal arteriography and intravenous pyelography. In 1962 35 patients at the UCLA Medical Center had all three studies. This represents a total of 70 kidneys (one kidney surgically absent). We found the radioactive renogram to be a very reliable and valuable aid in the diagnosis of kidney disease. When compared with the results of the intravenous pyelogram and aortogram, the renogram had false negative result in 11 per cent of cases, and a 14 per cent false positive result.     

Renal artery stenosis and ipsilateral renal cell carcinoma: description of an in situ partial nephrectomy and splenorenal arterial bypass

A case of a renal artery stenosis and ipsilateral renal cell carcinoma with long term results is reported. A 65-year-old man with renovascular hypertension, renal insufficiency, and nephrotic range proteinuria presented with an incidental renal cell carcinoma. Concomitant in situ left partial nephrectomy and splenorenal arterial bypass was achieved. The patient is doing well without evidence of malignancy, stable renal function, markedly improved proteinuria and stable blood pressure more than three years later. The techniques of this procedure are detailed and underscore the possibility of successful removal of a renal cell carcinoma with preservation of renal function despite renal artery stenosis.     

冠状动脉CTA和DSA对冠心病患者的临床诊断价值比较

目的:比较冠状动脉CT血管成像(CT angiography,CTA)以及数字减影血管造影(digital subtraction angiography,DSA)诊断冠心病的临床价值差异。方法:选择2013年12月至2020年3月安徽医科大学第三附属医院、安徽医科大学第四附属医院收治的60例冠心病患者为研究对象,首先对其实施多排螺旋CT冠状动脉血管造影检测(CTA),而后2 w内再对其实施DSA检测,比较两种检测方式对不同血管狭窄程度、不同性质斑块检出率的差异,最后以DSA检测结果为金标准,评估CTA对冠状动脉狭窄诊断的一致性、灵敏度、特异度、阳性预测值和阴性预测值。结果:(1)CTA检测狭窄血管共计387支,轻度狭窄152支(39.28%),中度狭窄118支(30.49%),重度狭窄105支(27.13%),闭塞12支(3.10%);DSA检测狭窄血管392支,轻度狭窄150支(38.27%),中度狭窄124支(31.63%),重度狭窄112支(28.57%),闭塞6支(1.53%),两组各血管狭窄类型比较差异无统计学意义(P0.05);(2)CTA检测斑块69个,其中钙化斑43个(62.32%),非钙化斑26个(37.68%),DSA检测斑块61个,其中钙化斑33个(54.10%),非钙化斑28个(45.50%),两种检测方式差异无统计学意义(P0.05);(3)以DSA检测为金标准,CTA对重度及以上血管狭窄诊断一致性为99.23%,特异度为98.31%,灵敏度为99.64%,阳性预测值为99.15%,阴性预测值为99.27%。结论:与DSA相比,CTA对冠心病患者血管狭窄的诊断价值相当,且属于无创检测,在冠心病早期筛查中临床应用价值更高。     

Renal actions of angiotensin II in renovascular hypertension

In renal artery stenosis severe enough to cause hypertension, angiotensin II maintains glomerular filtration rate (GFR) both in the initial high renin phase of hypertension and later when plasma levels are normal. Angiotensin II also maintains GFR in less severe stenosis, which does not cause hypertension. This homeostatic action of angiotensin II to maintain GFr has minimal effects on blood flow. In renal-wrap hypertension, plasma renin levels are elevated for longer than after renal artery stenosis, but in other respects this initial phase of the hypertension is similar to that after renal artery stenosis. GFR is reduced, the rate of development of hypertension is accelerated by angiotensin II, and angiotensin II maintains the glomerular filtration fraction. Renal resistance is markedly increased owing to both compression of the kidney by the hypertrophying renal capsule and to angiotensin II. Thus angiotensin II apparently plays a primarily homeostatic role in renovascular hypertension to maintain glomerular ultrafiltration. It is suggested that the angiotensin II may be formed intrarenally and may act on sites other than resistance blood vessels.     

Digital vascular imaging and selective renin sampling in evaluation of vascular anatomy in renal transplant recipients.

Sixty-five renal transplant recipients underwent digital vascular imaging of the graft and simultaneous selective venous sampling for plasma renin activity. Renal artery stenosis was found in seven patients but did not appear to be functionally important. Diffuse intrarenal arterial attenuation was found in seven patients and was associated with impaired graft function and perfusion; it may indicate chronic rejection. Lower pole hypoperfusion was found in nine patients without impaired graft function or perfusion; its clinical relevance is uncertain. Aneurysmal dilatation of the main renal artery was found in two patients. Severe hypertension was common in patients with these three major abnormalities, but a causal association between the abnormality and hypertension could rarely be inferred. It may be the abnormalities on digital vascular imaging, especially diffuse intrarenal arterial attenuation and lower pole hypoperfusion, are secondary to severe hypertension. Digital vascular imaging with simultaneous selective venous sampling for plasma renin activity is useful in evaluating the vascular anatomy of the grafted kidney and in assessing any abnormality found. The combined procedure was well tolerated by all patients with no complications and no incidence of acute tubular dysfunction or proteinuria after the investigation.     

Vascular Manifestations of von Recklinghausen's Disease

A casual relationship between von Recklinghausen''s disease, or neurofibromatosis, and arteriolar abnormalities has been reported in the European literature. A patient was seen who had biopsy-proved neurofibromatosis and renovascular hypertension and retroperitoneal bleeding. An arteriographic study showed multiple small aneurysms throughout the coeliac axis, the superior mesenteric artery and in several small intrarenal vessels. Renal vein renin levels were elevated particularly in the right renal vein, supporting the diagnosis of renovascular hypertension. Both the aneurysms seen in angiographic studies and the retroperitoneal hemorrhage are probably vascular manifestations of von Recklinghausen''s disease. Support for this conclusion is enhanced by the absence of clinical, laboratory or histologic data supporting the only tenable differential diagnosis, periarteritis nodosa.     

Kidney function after renal arterial embolism

Seven patients with atrial fibrillation had acute unilateral renal pain associated with suppression of function in the affected kidney. This was ascribed to renal embolism. Arteriography performed in four patients showed abnormalities in the renal arterial tree in three, though thrombus in a main artery was present in only one.Considerable function returned spontaneously to the affected kidney in six patients as judged by intravenous pyelography or renography. In two patients the sole functioning kidney was affected, leading to acute oliguric renal failure, but renal function recovered in each case. The routine use of anticoagulants in persistent atrial fibrillation is justified by such cases.     

The role and rationale of nuclear medicine procedures in the differential diagnosis of renovascular hypertension

The use of radionuclides in the differential diagnosis of renovascular hypertension has gone through many periods of enthusiasm and of disappointment. Regardless of the problems with the routine renogram, the availability of gamma camera renal evaluation makes possible meaningful preintervention of screening. The use of the test as a follow-up procedure is an extremely important but often overlooked application of radionuclides in the evaluation of renovascular hypertension. The radionuclide technique is a sensitive and accurate method of evaluating the results of percutaneous angioplasty or surgery or renal function in the affected kidney of patients with renovascular disease.A major change in our approach to the nuclear medicine diagnosis of renovascular hypertension has been the introduction of captopril renography. Although there is still a great deal of work to be done and many investigators are actively studying captopril renography, the potential of the test is clear. Captopril renography should include a baseline renogram, followed by the administration of 25 mg of captopril and a repeat study.Specificity and sensitivity data on this test probably will not be available for several years, but preliminary results are encouraging enough to justify routine use at this time in clinics in which screening for renovascular hypertension is carried out.     

Abdominal Bruit after Renal Transplantation

Forty-seven recipients of renal allografts have been studied at varying intervals of up to five years after transplantation. Renal artery bruit occurred in eight of 16 patients observed over the first two post-transplant months and disappeared spontaneously in four of these. The disappearance of the bruit was associated with poor renal function. Renal bruits were audible in 10 patients examined more than two months after transplantation; nine of these were hypertensive and of six in whom arteriography was performed five were shown to have stenosis of the allograft artery. By contrast only eight of 37 patients without abdominal bruit were hypertensive, and arteriography in 10 normotensive patients without bruit showed no stenosis. It is concluded that while a renal artery bruit during the first two months after transplantation may be a marker of good renal blood flow at the time, its presence suggests a poor long-term prognosis since persistence of the murmur indicates that significant stenosis of the allograft artery is likely, while its disappearance is associated with poor renal function.     

Blood pressure response to percutaneous transluminal angioplasty for renovascular hypertension: an overview of published series.

OBJECTIVE--To evaluate the efficacy and safety of transluminal angioplasty in the treatment of renovascular hypertension. DESIGN--Overview of 10 published case series. SETTING--Mostly tertiary referral centres. PATIENTS--691 Patients treated by angioplasty for renovascular hypertension, 464 for atherosclerotic stenosis, 193 for fibromuscular stenosis, and the remainder mainly for post-transplant stenosis. The inclusion criteria varied considerably between studies. INTERVENTIONS--Percutaneous transluminal renal artery angioplasty (successful or attempted); prophylaxis against restenosis in most cases. Policies on antihypertensive drug treatment and follow up varied. MAIN OUTCOME MEASURES--Blood pressure response as defined in the individual papers, with each patient classified as either cured, improved, or failed. Each study used a different definition of improvement in blood pressure. Complication rates. RESULTS--Follow up data were available for 670 patients. The procedure was technically successful in 611 patients (88%). The overall cure rate for hypertension was 24% (163 patients) and a further 43% (286) were "improved." There were large and significant variations between studies in the rate of technical success and also the blood pressure outcome. In each series patients with fibromuscular lesions, had a higher cure rate than those with atherosclerotic lesions (overall cure 50% v 19% odds ratio 3.9, 95% confidence interval 2.6 to 6.0). Complications were reported in 63 (9%) patients and three patients died (0.4%). CONCLUSIONS--The evidence for the value of angioplasty in treating renovascular hypertension has serious limitations. Angioplasty for fibromuscular disease seems to be worth while, but for atherosclerotic lesions the benefit appears to be small and its efficacy needs to be compared with medical therapy in randomised trials. These findings emphasise the importance of early formal evaluation of new therapeutic techniques.     

Value of antenatal diagnosis of abnormalities of the urinary tract.

OBJECTIVE--To assess the value of antenatal diagnosis of abnormalities of the urinary tract on ultrasonography. DESIGN--Retrospective study. SETTING--Two obstetric units in Glasgow. SUBJECTS--62 Fetuses in which renal abnormalities were diagnosed on antenatal ultrasonography. INTERVENTIONS--Six fetuses had their bladders aspirated to determine renal function. Fifteen pregnancies were terminated on the basis of the findings on antenatal ultrasonography, and if possible necropsy was performed on the fetuses. In babies who were born alive the final diagnosis was made by postnatal ultrasonography, intravenous urography, radionuclide scanning, cystography, and, in those who died in the early neonatal period, necropsy. Neonates who were referred with a known obstructed kidney had nephrostomy or pyeloplasty. END POINT--Assessment of the value of antenatal diagnosis of renal abnormalities on ultrasonography for babies who had no clinical evidence of disease postnatally. MAIN RESULTS--Eighteen fetuses did not survive birth; the antenatal diagnosis was accurate in all 18. Of the 44 babies born alive, five had normal urinary tracts, in two of whom antenatal ultrasonography had probably indicated a false positive diagnosis. Fourteen babies died during the early neonatal period. Twenty five babies with renal abnormalities were followed up; the antenatal diagnosis was inaccurate for 10 of them, the commonest misdiagnosis being hydronephrosis for multicystic kidney and vice versa, and there was one false positive diagnosis. The initial clinical findings in 14 babies would have led to the early detection of a urological abnormality. In the 30 babies with no clinical evidence of disease the antenatal diagnosis was of definite value in eight, probable value in 15, and marginal value in seven. Overall, an accurate antenatal diagnosis was made in 46 of the 62 cases (74%); in 12 cases renal disease was detected but its specific nature was not determined; and in four cases the diagnosis was misleading. CONCLUSIONS--The overall value of antenatal diagnosis is that it indicates early termination of fetuses with fatal renal disease, prepares parents and medical staff for the likelihood of serious neonatal problems, and shows abnormalities of the urinary tract that may not be detected postnatally.     

Radiopertechnetate renography with the gamma ray scintillation camera

Radiopertechnetate renography merits consideration as another intravenous screening procedure for renovascular hypertension. Thus far in our experience it has yielded fewer falsely negative results than the radiohippurate renogram, and it takes less than one minute to complete. Applications of this method to the assessment of renal perfusion in other renal afflictions are described. The examination requires a stationary imaging device interfaced with a storage device and a data processor. It has the advantage of providing a comparison of renal transit of the test agent with its transit through the systemic circulation, e.g. the aorta.     

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.