Hypertensive and ischemic nephropaties renovascular diseases Zehra Eren
- Slides: 58
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
Clinical manifestations of renovascular disease Asemptomatic ‘’İncidental Renal Artery Stenosis (RAS)’’ Renovascular Hypertension İschemic Nephropathy Accelerated CV Disease -Congestive heart failure -Stroke -Secondary aldosteronism
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
Clinical manifestations of renovascular disease Asemptomatic ‘’İncidental Renal Artery Stenosis’’ Renovascular Hypertension İschemic Nephropathy Accelerated CV Disease -Congestive heart failure -Stroke -Secondary aldosteronism
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
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
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