Hypertensive and ischemic nephropaties renovascular diseases Zehra Eren

LEARNING OBJECTIVES • explain hypertansion and renal disease interaction, • describe renovascular diseases •

Clinical manifestations of renovascular disease Asemptomatic ‘’İncidental Renal Artery Stenosis’’ Renovascular Hypertension İschemic Nephropathy

Clinical manifestations of renovascular disease Asemptomatic ‘’İncidental Renal Artery Stenosis (RAS)’’ Renovascular Hypertension İschemic

Asemptomatic ‘’İncidental Renal Artery Stenosis’’ Some degree of RAS can be identified in 20%45%

Renovascular Hypertension Reduced renal perfusion Rise in arterial pressure Diagnosis is established only in

Lesions producing renovascular hypertension

Fibromuscular Disease 3%-5%, Medial F>M fibroplasia is the most common Location: Smoking midportion of

Atherosclerosis Most common renovascular lesion (75% - 84%) Location: origin of artery Associated with

Changes of renin-angiotensin system in renovascular hypertension

Disease progression in atherosclerotic renal artery stenosis

Pathophysiology of ischemic renal disease

Goals of Diagnostic Evaluation Establish presence of RAS: location and type of lesion Establish

Diagnostic Testing for Renovascular Hypertension and İschemic Nephropathy Physiologic and functional studies of the

Gadolinium-enhanced magnetic resonance (MR) angiography

Goals of Therapy Improved Prevent BP morbidity and mortality Preservation of renal function

Therapy Medical Surgical therapy -angioplasty and stent replacement

Serum creatinine and blood pressure levels before and after percutaneous renal artery angioplasty (PTRA)

Clinical Factors Favoring Medical Therapy and Revascularization or Surveillance for Renal Artery Stenosis

Peripheral manifestations of atheroembolic disease

Occlusion of the left main renal artery by a metastatic deposit

Successful embolization of a large right renal artery aneurysm

Microvascular renal diseases Hemolytic- Uremic Syndrome (HUS) Thrombotic- (TTP) Thrombocytopenic Purpura

Clinic presentation of HUS/TTP Microangiopathic hemolytic anemia Thrombocytopenic Acute purpura renal failure Fever Neurologic

Etiology and pathogenesis of microangiopathy

Peripheral blood smear from a patient with HUS

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Hypertensive and ischemic nephropaties, renovascular diseases Zehra Eren, M. D.

LEARNING OBJECTIVES • explain hypertansion and renal disease interaction, • describe renovascular diseases • describe diagnostic evaluation • explan therapy in renovascular deseases • describe and manage renal artery and vein thrombosis • explain microvascular renal diseases

Hypertension and renal disease

Clinical manifestations of renovascular disease Asemptomatic ‘’İncidental Renal Artery Stenosis’’ Renovascular Hypertension İschemic Nephropathy Accelerated CV Disease -Congestive heart failure -Stroke -Secondary aldosteronism

Clinical manifestations of renovascular disease Asemptomatic ‘’İncidental Renal Artery Stenosis (RAS)’’ Renovascular Hypertension İschemic Nephropathy Accelerated CV Disease -Congestive heart failure -Stroke -Secondary aldosteronism

Asemptomatic ‘’İncidental Renal Artery Stenosis’’ Some degree of RAS can be identified in 20%45% of patients undergoing vascular imaging Most of these stenoses are of little or no hemodynamic significance

Pathogenesis

Renovascular Hypertension Reduced renal perfusion Rise in arterial pressure Diagnosis is established only in retrospect after succesful reversal of HT with revascularization

Lesions producing renovascular hypertension

Fibromuscular Disease 3%-5%, Medial F>M fibroplasia is the most common Location: Smoking midportion of the vessel is a risk factor for progression

FMD

Atherosclerosis Most common renovascular lesion (75% - 84%) Location: origin of artery Associated with HT, DM, HPL, smoking, abnormal renal function

Bilateral RAS

Changes of renin-angiotensin system in renovascular hypertension

Clinical features

Clinical syndromes

Disease progression in atherosclerotic renal artery stenosis

Pathophysiology of ischemic renal disease

Goals of Diagnostic Evaluation Establish presence of RAS: location and type of lesion Establish whether unilateral or bilateral stenosis (or stenosis to a solitary kidney) Establish presence and function of stenotic and nonstenotic kidneys Establish hemodynamic severity of renal arteral disease Plan vascular intervention

Diagnostic Testing for Renovascular Hypertension and İschemic Nephropathy Physiologic and functional studies of the Renin-Angiotensin system -plasma renin levels -measurement of renal vein renin levels Noninvasive imaging and assesment of the renal vasculature -Doppler USG -radyonuclide imaging -magnetic resonance arteriography -computed tomographic angiography

Doppler ultrasonography

Gadolinium-enhanced magnetic resonance (MR) angiography

Computed tomography angiogram

Angiography

Goals of Therapy Improved Prevent BP morbidity and mortality Preservation of renal function

Therapy Medical Surgical therapy -angioplasty and stent replacement

Serum creatinine and blood pressure levels before and after percutaneous renal artery angioplasty (PTRA)

Clinical Factors Favoring Medical Therapy and Revascularization or Surveillance for Renal Artery Stenosis

Disorders of Renal Arteries and Veins

Causes of renal artery thrombosis

Symptoms of renal artery occlusion

Peripheral manifestations of atheroembolic disease

Acute focal infarct

Occlusion of the left main renal artery by a metastatic deposit

Successful embolization of a large right renal artery aneurysm

Segmental renal artery occlusions

Causes of renal vein thrombosis

Symptoms of renal vein thrombosis

Acute renal vein thrombosis

Microvascular renal diseases Hemolytic- Uremic Syndrome (HUS) Thrombotic- (TTP) Thrombocytopenic Purpura

Clinic presentation of HUS/TTP Microangiopathic hemolytic anemia Thrombocytopenic Acute purpura renal failure Fever Neurologic dysfunction

Etiology and pathogenesis of microangiopathy

Peripheral blood smear from a patient with HUS