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HYPERTENSION AND MULTIPLE RENAL ARTERIES
556
that the patients’ requirements are met. Ward sisters obtain supplies of necessary drugs as required from the hospital pharmacy, and ward stocks are subject to periodic review by the central pharmacy. This is the practice in the Aberdeen General Hospitals for which this prescription sheet was devised."-ED. L. HYPERTENSION AND MULTIPLE RENAL ARTERIES SIR,-We have read with interest the article by Dr.
Davies and Dr. Sutton (Feb. 13) which makes frequent reference to work we published in 1962 1: our suggestion that multiple renal arteries can be demonstrated more frequently in certain kinds of hypertension is disputed. It is remarkable that in their article they have failed to indithe types of hypertension investigated, for our main point was that only after full assessment did the multiple artery pattern assume significance. We noted the presence of multiple renal arteries in some 70% of those patients with no conventional explanation for their hypertension. This was contrasted with an estimated incidence of between 20% and 30% for normotensive patients. Until and unless Dr. Davies and Dr. Sutton can provide full details of their 550 patients their comments have little relevance to our observations. In their paper Dr. Davies and Dr. Sutton omitted to quote fully from work supporting our views. Thus Davies et al. in a paper based on angiographic studies of 352 patients stated: " This study supplements previous anatomic and angiographic work in showing ... that multiple renal arteries are more often found in hypertensive than in normotensive patients." To suggest that confusion exists because " some workers measured the incidence in terms of kidneys ... and others in terms of patients " in their statistics merely draws a false trail across this subject. Clearly a unilateral renal anomaly may be as important in the xtiology of hypertension as one which is bilateral. We certainly did not obtain our figures by adding, up the number of kidneys involved. Davies et al. also based their figures on patient-numbers. We therefore fail to see why Dr. Davies and Dr. Sutton dismiss the various series to which they refer. Since our original paper we have completed full studies on a further large series of hypertensive patients, and the results from the first 240 have been analysed.3 The findings follow closely those noted in our original paper and, in summary, show that about 68% of those with idiopathic hypertension had an anomalous renal artery supply to at least one kidney. Thus, over a period of some five years, and with 361 patients assessed in full detail in our own hypertensive unit, we have consistently observed a high incidence of arterial anomaly in our patients with idiopathic hypertension. Why then do our figures differ so much from those of Dr. Davies and Dr. Sutton ? There may be a variety of explanations. In the first place the figures may not be as different as at first appears, for full details of their patients may demonstrate that the incidence of multiple arteries amongst the idiopathic group is much higher. A second possibility is that the patients in their series may be a more selected group than ours: their well-known interest in renal artery stenosis and other renal disorders may have loaded the series heavily against idiopathic hypertension. In our second series about 60°,o were classified as idiopathic hypertension : the incidence of multiple arteries in the secondaryhypertension group was 27%, which is near to their figures. Finally, despite assertions to the contrary, faulty technique may have led to accessory arteries being missed. We find surprising their suggestion that selective renal-artery catheterisation is the method of choice, for not only is this a more difficult and protracted method which is open to a variety of technical criticisms but it may fail to show details of the origin of the cate
1.
2. 3.
Robertson, P. W., Klidjian, A., Hull, D. H., Hilton, D. D., Dyson, M. L. Lancet, 1962, ii, 567. Davies, G. D., Kmcaid, O. W., Hunt, V. C., Bermudez, R. Amer. J. Roentgenol. 1963, 90, 583. Robertson, P. W., Klidjian, A., Hull, D. H., Dyson, M. L. Unpublished.
renal artery and of widely spaced multiple arteries. We have been saying this for years but we can do no better than quote from a recent publication 4: " While a midstream aortic injection with the catheter tip just below the origin of the renal arteries is completely adequate for renal arteriography in most cases, selective renal angiography may occasionally be indicated for good visualisation of the renal vessels. Since selective renal angiography may not permit good visualisation of the ostium of the renal artery and will not permit visualisation of aberrant arteries to the kidney, aortic injection should always be done in addition when selective renal arteriography is employed. Visualisation of aberrant renal arteries is extremely important. Visualisation of the entire abdominal aorta and proximal iliac arteries must always be obtained since these vessels may arise anywhere between the level of the 12th thoracic vertebra and the proximal iliac arteries."
In their series Dr. Davies and Dr. Sutton used the selective technique in 316 patients but free injection in only 87. Since the former method is, in our opinion, suspect, so too will be any figures which are based upon such an unbalanced series. PHILIP W. ROBERTSON A. KLIDJIAN D. H. HULL R.A.F. Hospital, Cosford, M. L. DYSON. Staffordshire. TRAINING OF MEDICAL LABORATORY TECHNICIANS
SIR,-We write
to correct an
unfortunately misleading
the letter by Dr. Grant (Feb. 27). The examinations board and the examining body for the final examinations of the Institute of Medical Laboratory Technology contain pathologists representing all the specialties and senior members of the Institute; the examiners are drawn equally from fellows of the Institute and medically qualified pathologists, with a few suitably experienced hospital biochemists. The examining body has been fortunate to have had long and devoted service, in the specialty of clinical chemistry to which Dr. Grant refers, from such eminent persons as Prof. N. H. Martin, Prof. 1. D. P. Wootton, and the late Prof. E. J. King. A. C. LENDRUM
statement in
Institute of Medical Laboratory Technology, 74, New Cavendish Street, London, W.1.
President
G. C. PASCOE Chairman.
SIR,-Dr. Grant attacks the Board of the Council for Professions Supplementary to Medicine for what he calls an "unenlightened policy", and seems to hint that the influence of the Institute of Medical Laboratory Technology is at least partly the cause. It is true that there are seven members of the I.M.L.T. on the Board. There are also five doctors and an expert in professional education, and there has been no dissension on the Board on the matters in issue. The Board was created by and must work within the framework of an Act of Parliament. That Act gave no guidance as to the meaning of the term " medical laboratory technician ", and the Board has had to consider a wide range of technicians; amongst them are the workers in clinical biochemical laboratories. The history of the negotiations with the Association of Clinical Biochemists and the Biochemical Society is rather different from that given by Dr. Grant. Their representatives, together with those of the Royal Institute of Chemistry, first met representatives of the Board in July, 1963. At that meeting, the Board representatives said that they would be prepared to consider a programme from the Association of Clinical Biochemists. This was not submitted until April, 1964. Another meeting was held in June. In October, 1964, the Association of 4.
Kincaid, O. W. in Progress in Angiography; p. 280. Springfield, Illinois, 1964.
that the patients’ requirements are met. Ward sisters obtain supplies of necessary drugs as required from the hospital pharmacy, and ward stocks are subject to periodic review by the central pharmacy. This is the practice in the Aberdeen General Hospitals for which this prescription sheet was devised."-ED. L. HYPERTENSION AND MULTIPLE RENAL ARTERIES SIR,-We have read with interest the article by Dr.
Davies and Dr. Sutton (Feb. 13) which makes frequent reference to work we published in 1962 1: our suggestion that multiple renal arteries can be demonstrated more frequently in certain kinds of hypertension is disputed. It is remarkable that in their article they have failed to indithe types of hypertension investigated, for our main point was that only after full assessment did the multiple artery pattern assume significance. We noted the presence of multiple renal arteries in some 70% of those patients with no conventional explanation for their hypertension. This was contrasted with an estimated incidence of between 20% and 30% for normotensive patients. Until and unless Dr. Davies and Dr. Sutton can provide full details of their 550 patients their comments have little relevance to our observations. In their paper Dr. Davies and Dr. Sutton omitted to quote fully from work supporting our views. Thus Davies et al. in a paper based on angiographic studies of 352 patients stated: " This study supplements previous anatomic and angiographic work in showing ... that multiple renal arteries are more often found in hypertensive than in normotensive patients." To suggest that confusion exists because " some workers measured the incidence in terms of kidneys ... and others in terms of patients " in their statistics merely draws a false trail across this subject. Clearly a unilateral renal anomaly may be as important in the xtiology of hypertension as one which is bilateral. We certainly did not obtain our figures by adding, up the number of kidneys involved. Davies et al. also based their figures on patient-numbers. We therefore fail to see why Dr. Davies and Dr. Sutton dismiss the various series to which they refer. Since our original paper we have completed full studies on a further large series of hypertensive patients, and the results from the first 240 have been analysed.3 The findings follow closely those noted in our original paper and, in summary, show that about 68% of those with idiopathic hypertension had an anomalous renal artery supply to at least one kidney. Thus, over a period of some five years, and with 361 patients assessed in full detail in our own hypertensive unit, we have consistently observed a high incidence of arterial anomaly in our patients with idiopathic hypertension. Why then do our figures differ so much from those of Dr. Davies and Dr. Sutton ? There may be a variety of explanations. In the first place the figures may not be as different as at first appears, for full details of their patients may demonstrate that the incidence of multiple arteries amongst the idiopathic group is much higher. A second possibility is that the patients in their series may be a more selected group than ours: their well-known interest in renal artery stenosis and other renal disorders may have loaded the series heavily against idiopathic hypertension. In our second series about 60°,o were classified as idiopathic hypertension : the incidence of multiple arteries in the secondaryhypertension group was 27%, which is near to their figures. Finally, despite assertions to the contrary, faulty technique may have led to accessory arteries being missed. We find surprising their suggestion that selective renal-artery catheterisation is the method of choice, for not only is this a more difficult and protracted method which is open to a variety of technical criticisms but it may fail to show details of the origin of the cate
1.
2. 3.
Robertson, P. W., Klidjian, A., Hull, D. H., Hilton, D. D., Dyson, M. L. Lancet, 1962, ii, 567. Davies, G. D., Kmcaid, O. W., Hunt, V. C., Bermudez, R. Amer. J. Roentgenol. 1963, 90, 583. Robertson, P. W., Klidjian, A., Hull, D. H., Dyson, M. L. Unpublished.
renal artery and of widely spaced multiple arteries. We have been saying this for years but we can do no better than quote from a recent publication 4: " While a midstream aortic injection with the catheter tip just below the origin of the renal arteries is completely adequate for renal arteriography in most cases, selective renal angiography may occasionally be indicated for good visualisation of the renal vessels. Since selective renal angiography may not permit good visualisation of the ostium of the renal artery and will not permit visualisation of aberrant arteries to the kidney, aortic injection should always be done in addition when selective renal arteriography is employed. Visualisation of aberrant renal arteries is extremely important. Visualisation of the entire abdominal aorta and proximal iliac arteries must always be obtained since these vessels may arise anywhere between the level of the 12th thoracic vertebra and the proximal iliac arteries."
In their series Dr. Davies and Dr. Sutton used the selective technique in 316 patients but free injection in only 87. Since the former method is, in our opinion, suspect, so too will be any figures which are based upon such an unbalanced series. PHILIP W. ROBERTSON A. KLIDJIAN D. H. HULL R.A.F. Hospital, Cosford, M. L. DYSON. Staffordshire. TRAINING OF MEDICAL LABORATORY TECHNICIANS
SIR,-We write
to correct an
unfortunately misleading
the letter by Dr. Grant (Feb. 27). The examinations board and the examining body for the final examinations of the Institute of Medical Laboratory Technology contain pathologists representing all the specialties and senior members of the Institute; the examiners are drawn equally from fellows of the Institute and medically qualified pathologists, with a few suitably experienced hospital biochemists. The examining body has been fortunate to have had long and devoted service, in the specialty of clinical chemistry to which Dr. Grant refers, from such eminent persons as Prof. N. H. Martin, Prof. 1. D. P. Wootton, and the late Prof. E. J. King. A. C. LENDRUM
statement in
Institute of Medical Laboratory Technology, 74, New Cavendish Street, London, W.1.
President
G. C. PASCOE Chairman.
SIR,-Dr. Grant attacks the Board of the Council for Professions Supplementary to Medicine for what he calls an "unenlightened policy", and seems to hint that the influence of the Institute of Medical Laboratory Technology is at least partly the cause. It is true that there are seven members of the I.M.L.T. on the Board. There are also five doctors and an expert in professional education, and there has been no dissension on the Board on the matters in issue. The Board was created by and must work within the framework of an Act of Parliament. That Act gave no guidance as to the meaning of the term " medical laboratory technician ", and the Board has had to consider a wide range of technicians; amongst them are the workers in clinical biochemical laboratories. The history of the negotiations with the Association of Clinical Biochemists and the Biochemical Society is rather different from that given by Dr. Grant. Their representatives, together with those of the Royal Institute of Chemistry, first met representatives of the Board in July, 1963. At that meeting, the Board representatives said that they would be prepared to consider a programme from the Association of Clinical Biochemists. This was not submitted until April, 1964. Another meeting was held in June. In October, 1964, the Association of 4.
Kincaid, O. W. in Progress in Angiography; p. 280. Springfield, Illinois, 1964.