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Solitary Renal Cyst with Segmental Ischemia and Hypertension
Vol. 112, November
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1974 by The Williams & Wilkins Co.
SOLITARY RENAL CYST WITH SEGMENTAL ISCHEMIA AND HYPERTENSION STANLEY G. ROCKSON, RICHARD A. STONE
AND
J. CAULIE GUNNELLS, ,JR.
From the Division of Nephrology, Duke University Medical Center, Durham, North Carolina
The solitary, unilateral renal cyst is productive of a recognized, although uncommon, form of surgically correctable hypertension. 1 Although it has been proposed that the associated hypertension is etiologically related to renal ischemia produced by the cyst, evidence for this hypothesis is often indirect. In our case cure of hypertension through cyst decompression alone was preceded by documentation of unilaterally elevated renal venous plasma renin activity, a finding which has been associated with surgically remediable hypertension in patients with unilateral renal ischemia secondary to renal artery stenos is. 2
stream aortic and selective renal artery injections) demonstrated patency of both renal arteries without evidence of proximal or distal stenosis (fig. 1, C). Although there was no distinctly definable area of vascular stenosis there was a suggestion of compression of several of the segmental arteries posterior to and at the inferior margin of the cyst (fig. 2, A). Differential renal venous renin samples yielded values of 570, 98 and 91 ng. angiotensin II per 100 ml. plasma for the left renal vein, right renal vein and inferior vena cava, respectively. After injection of the cyst with contrast material, which demonstrated a benign appearance (fig. 2, B), the remaining cyst fluid was aspirated (fig. 2, C). After this procedure the blood pressure was recorded as 120/80 mm. Hg. For the remainder of the hospital course the blood pressure remained within the range of 110 to 120/80 mm. Hg, and at discharge from the hospital normotension persisted, requiring no further antihypertensive therapy. Blood pressures have remained at or less than 130/80 mm. Hg throughout 9 months of followup.
CASE REPORT
W. B., a 60-year-old white man, was admitted to the hospital for evaluation of a 2-year history of recurrent substernal chest pain. Evaluation for high blood pressure at another hospital approximately 6 years earlier had demonstrated the presence of a left renal cyst that was benign on cytology studies of the cyst aspirate. During the interval the patient was followed with periodic office visits and was found to remain mildly hypertensive without medication. During the present hospitalization and throughout the period of diagnostic evaluation the blood pressure remained in the range of 140 to 210/110 mm. Hg. The patient had been on a normal dietary sodium and potassium intake and on no antihypertensive drugs. Fundoscopic examination revealed distinct arteriolar narrowing without arteriovenous nicking, hemorrhages or exudates. The remainder of the physical examination was within normal limits. Routine hematologic and biochemical studies, including a urinalysis, revealed no abnormalities (creatinine 1.0 mg. per 100 ml. and blood urea nitrogen 18 mg. per 100 ml.). Additional laboratory findings included a serum lipid profile compatible with type IV hyperlipoproteinemia. Hypertensive evaluation included a rapid sequence excretory urogram (IVP), which disclosed a large peripelvic cyst in the left kidney with normal and equal appearance of contrast medium (fig. 1, A and B). The renal outlines were normal with smooth contours and no significant discrepancy in over-all renal size. Renal arteriography (mid-
DISCUSSION
Since Goldblatt's classic investigations into the relationship between renal ischemia and hypertension, considerable attention has been directed to the detection and recognition of unilateral renal diseases which might represent surgically correctable forms of hypertension. 3 • 4 Renal artery stenosis, intrarenal arterial aneurysm, 5 intrarenal arteriovenous fistula,6 unilateral hydronephrosis 7 and solitary, unilateral renal cyst 1 are among those conditions associated with hypertension which have been cured through renal revascularization, nephrectomy or other operative procedures. The earliest discussion of surgical reversal of the hypertension associated with solitary renal cyst was reported in 1942. 8 That report concerns the 'Vidt, D. G. and Gifford, R. W., Jr.: Reversible renal hypertension. Cardiovasc. Clin., 1: 131, 1969. ' Kaufman, J. J., Maxwell, M. H., Craven, J. D. and Okun, R.: Hypertension-primary and secondary. Ann. Intern. Med., 75: 761, 1971. 5 O'Conor, V. J.: Hypertension with intrarenal arterial aneurysm. Relief by nephrectomy. New Engl. J. Med., 262: 456, 1960. 'Riba, L. W. and Simon, M. P.: Intrarenal arteriovenous fistula treated with partial nephrectomy. J. Urol., 98: 293, 1967. 'Belman, A. B., Kropp, K. A. and Simon, N. M.: Renal-pressor hypertension secondary to unilateral hydronephrosis. New Engl. J. Med., 278: 113:i, 1968. 'Farrell, J. I. and Young, R.H.: Hypertension caused by unilateral renal compression. J.A.M.A., 118: 711, 1942.
Accepted for publication April 19, 197 4. 1 Hunt, J. C., Strong, C. G., Harrison, E. G., Jr. and Furlow, W. L.: Hypertension associated with parenchymal renal disease. Cardiovasc. Clin., 1: 113, 1969. 'Gunnells, J. C., Jr., McGuffin, W. L., Jr., Johnsrude, I. and Robinson, R. R.: Peripheral and renal venous plasma renin activity in hypertension. Ann. Intern. Med., 71: 555, 1969. 550
SOLITARY RENAL CYST WITH SEGMENTAL ISCHEMIA AND 1-!YPERTENSION
IVPs and C, renal arteriogram demonstrate large, peripelvic renal cyst
of segmental vascular compression at inferior margin of cysL B, cyst filled C, urogram phase demonstrates complete decompression of cysL
ren10val of a cyst which consequent to blunt abdominal trauma, of the in the vvalls of the cyst. comment upon the the involved
around mens in an attempt to define anatomical correlates to the renal ischemia. 10 · 11 In 1956 Smith "AY,rn•,,A~ on the treatment of m 149 cases and renal cysts were noted in 2. 12 In a review of 500 selected cases of of renal 100
.
~:11ith, I-L
s1ve arnease<
patients ated with renal cysts of all men, with a slightly sion than in the other clinical
served cysts were view incidence of familial in these patient:, it appears of some importance to demonstrate 1/u,au,u,~ presence of ischemia if one directed toward the cure of tension. Advances in our physiology of the gether with the cf peripheral and renal wide variety of have led to the application of these measurements the assessment of the functional 01 van on,; lesions of unilateral ischemia. utilization of these methods leads to proper selection of patients for surgical inter1Emtion in the treatment of hypertension. 2 Nevertheless, to our this is the first recorded case of reversal of
552
ROCKSON, STONE AND GUNNELLS
tension following therapeutic renal cyst decompression in which a preoperative elevation in plasma renin activity had been documented. The criteria for renal vein renin ratios, which have been traditionally applied to the detection of functionally significant renal artery stenosis, have been demonstrated to be diagnostically valid in other forms of renal hypertension. 14 The criteria for a functionally significant lesion are well met in this case, with a renal venous renin activity ratio of approximately 6 to 1 and a ratio of contralateral renal venous renin activity to peripheral activity approaching unity. These renin values, coupled with a renal arteriogram which is suggestive of segmental arterial compression, would lead us to believe that we have indeed demonstrated a renal cyst which was producing significant segmental ischemia, with increased secretion ofrenin, leading to the observed diastolic hypertension. More recently, the use of segmental, rather than main-stem, renal vein renin samples has been reported to be more effective or reliable in the
detection of segmental renal ischemia. 15 This refinement in the ability to specifically localize and define the source of renin release should lead to increased detection and understanding of patients with segmental renal ischemic lesions of varied etiologies and hopefully lead to the reduction of blood pressure in these patients by the application of appropriate surgical procedures. SUMMARY
Hypertensive evaluation of a 60-year-old patient with moderate to severe elevations in blood pressure disclosed a unilateral peripelvic renal cyst. Functionally significant renal ischemia was documented with unilaterally elevated renal venous plasma renin activity. Therapeutic decompression of the cyst produced normalization of blood pressure. As documented in this and other reported cases, selective renal vein renin determinations have great potential applicability in the diagnosis of ischemia secondary to unilateral renal lesions other than main-stem renal artery stenosis. Dr. Robert E. Whalen permitted the use of his patient for this report.
14 Stockigt, J. R., Collins, R. D., Noakes, C. A., Schambelan, M. and Biglieri, E.G.: Renal-vein renin in various forms of renal hypertension. Lancet, I: 1194, 1972.
15 Stockigt, J. R., Hertz, P., Schambelan, M. and Biglieri, E. G.: Segmental renal-vein renin sampling for segmental renal infarction. Studies in a hypertensive patient. Ann. Intern. Med., 79: 67, 1973.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1974 by The Williams & Wilkins Co.
SOLITARY RENAL CYST WITH SEGMENTAL ISCHEMIA AND HYPERTENSION STANLEY G. ROCKSON, RICHARD A. STONE
AND
J. CAULIE GUNNELLS, ,JR.
From the Division of Nephrology, Duke University Medical Center, Durham, North Carolina
The solitary, unilateral renal cyst is productive of a recognized, although uncommon, form of surgically correctable hypertension. 1 Although it has been proposed that the associated hypertension is etiologically related to renal ischemia produced by the cyst, evidence for this hypothesis is often indirect. In our case cure of hypertension through cyst decompression alone was preceded by documentation of unilaterally elevated renal venous plasma renin activity, a finding which has been associated with surgically remediable hypertension in patients with unilateral renal ischemia secondary to renal artery stenos is. 2
stream aortic and selective renal artery injections) demonstrated patency of both renal arteries without evidence of proximal or distal stenosis (fig. 1, C). Although there was no distinctly definable area of vascular stenosis there was a suggestion of compression of several of the segmental arteries posterior to and at the inferior margin of the cyst (fig. 2, A). Differential renal venous renin samples yielded values of 570, 98 and 91 ng. angiotensin II per 100 ml. plasma for the left renal vein, right renal vein and inferior vena cava, respectively. After injection of the cyst with contrast material, which demonstrated a benign appearance (fig. 2, B), the remaining cyst fluid was aspirated (fig. 2, C). After this procedure the blood pressure was recorded as 120/80 mm. Hg. For the remainder of the hospital course the blood pressure remained within the range of 110 to 120/80 mm. Hg, and at discharge from the hospital normotension persisted, requiring no further antihypertensive therapy. Blood pressures have remained at or less than 130/80 mm. Hg throughout 9 months of followup.
CASE REPORT
W. B., a 60-year-old white man, was admitted to the hospital for evaluation of a 2-year history of recurrent substernal chest pain. Evaluation for high blood pressure at another hospital approximately 6 years earlier had demonstrated the presence of a left renal cyst that was benign on cytology studies of the cyst aspirate. During the interval the patient was followed with periodic office visits and was found to remain mildly hypertensive without medication. During the present hospitalization and throughout the period of diagnostic evaluation the blood pressure remained in the range of 140 to 210/110 mm. Hg. The patient had been on a normal dietary sodium and potassium intake and on no antihypertensive drugs. Fundoscopic examination revealed distinct arteriolar narrowing without arteriovenous nicking, hemorrhages or exudates. The remainder of the physical examination was within normal limits. Routine hematologic and biochemical studies, including a urinalysis, revealed no abnormalities (creatinine 1.0 mg. per 100 ml. and blood urea nitrogen 18 mg. per 100 ml.). Additional laboratory findings included a serum lipid profile compatible with type IV hyperlipoproteinemia. Hypertensive evaluation included a rapid sequence excretory urogram (IVP), which disclosed a large peripelvic cyst in the left kidney with normal and equal appearance of contrast medium (fig. 1, A and B). The renal outlines were normal with smooth contours and no significant discrepancy in over-all renal size. Renal arteriography (mid-
DISCUSSION
Since Goldblatt's classic investigations into the relationship between renal ischemia and hypertension, considerable attention has been directed to the detection and recognition of unilateral renal diseases which might represent surgically correctable forms of hypertension. 3 • 4 Renal artery stenosis, intrarenal arterial aneurysm, 5 intrarenal arteriovenous fistula,6 unilateral hydronephrosis 7 and solitary, unilateral renal cyst 1 are among those conditions associated with hypertension which have been cured through renal revascularization, nephrectomy or other operative procedures. The earliest discussion of surgical reversal of the hypertension associated with solitary renal cyst was reported in 1942. 8 That report concerns the 'Vidt, D. G. and Gifford, R. W., Jr.: Reversible renal hypertension. Cardiovasc. Clin., 1: 131, 1969. ' Kaufman, J. J., Maxwell, M. H., Craven, J. D. and Okun, R.: Hypertension-primary and secondary. Ann. Intern. Med., 75: 761, 1971. 5 O'Conor, V. J.: Hypertension with intrarenal arterial aneurysm. Relief by nephrectomy. New Engl. J. Med., 262: 456, 1960. 'Riba, L. W. and Simon, M. P.: Intrarenal arteriovenous fistula treated with partial nephrectomy. J. Urol., 98: 293, 1967. 'Belman, A. B., Kropp, K. A. and Simon, N. M.: Renal-pressor hypertension secondary to unilateral hydronephrosis. New Engl. J. Med., 278: 113:i, 1968. 'Farrell, J. I. and Young, R.H.: Hypertension caused by unilateral renal compression. J.A.M.A., 118: 711, 1942.
Accepted for publication April 19, 197 4. 1 Hunt, J. C., Strong, C. G., Harrison, E. G., Jr. and Furlow, W. L.: Hypertension associated with parenchymal renal disease. Cardiovasc. Clin., 1: 113, 1969. 'Gunnells, J. C., Jr., McGuffin, W. L., Jr., Johnsrude, I. and Robinson, R. R.: Peripheral and renal venous plasma renin activity in hypertension. Ann. Intern. Med., 71: 555, 1969. 550
SOLITARY RENAL CYST WITH SEGMENTAL ISCHEMIA AND 1-!YPERTENSION
IVPs and C, renal arteriogram demonstrate large, peripelvic renal cyst
of segmental vascular compression at inferior margin of cysL B, cyst filled C, urogram phase demonstrates complete decompression of cysL
ren10val of a cyst which consequent to blunt abdominal trauma, of the in the vvalls of the cyst. comment upon the the involved
around mens in an attempt to define anatomical correlates to the renal ischemia. 10 · 11 In 1956 Smith "AY,rn•,,A~ on the treatment of m 149 cases and renal cysts were noted in 2. 12 In a review of 500 selected cases of of renal 100
.
~:11ith, I-L
s1ve arnease<
patients ated with renal cysts of all men, with a slightly sion than in the other clinical
served cysts were view incidence of familial in these patient:, it appears of some importance to demonstrate 1/u,au,u,~ presence of ischemia if one directed toward the cure of tension. Advances in our physiology of the gether with the cf peripheral and renal wide variety of have led to the application of these measurements the assessment of the functional 01 van on,; lesions of unilateral ischemia. utilization of these methods leads to proper selection of patients for surgical inter1Emtion in the treatment of hypertension. 2 Nevertheless, to our this is the first recorded case of reversal of
552
ROCKSON, STONE AND GUNNELLS
tension following therapeutic renal cyst decompression in which a preoperative elevation in plasma renin activity had been documented. The criteria for renal vein renin ratios, which have been traditionally applied to the detection of functionally significant renal artery stenosis, have been demonstrated to be diagnostically valid in other forms of renal hypertension. 14 The criteria for a functionally significant lesion are well met in this case, with a renal venous renin activity ratio of approximately 6 to 1 and a ratio of contralateral renal venous renin activity to peripheral activity approaching unity. These renin values, coupled with a renal arteriogram which is suggestive of segmental arterial compression, would lead us to believe that we have indeed demonstrated a renal cyst which was producing significant segmental ischemia, with increased secretion ofrenin, leading to the observed diastolic hypertension. More recently, the use of segmental, rather than main-stem, renal vein renin samples has been reported to be more effective or reliable in the
detection of segmental renal ischemia. 15 This refinement in the ability to specifically localize and define the source of renin release should lead to increased detection and understanding of patients with segmental renal ischemic lesions of varied etiologies and hopefully lead to the reduction of blood pressure in these patients by the application of appropriate surgical procedures. SUMMARY
Hypertensive evaluation of a 60-year-old patient with moderate to severe elevations in blood pressure disclosed a unilateral peripelvic renal cyst. Functionally significant renal ischemia was documented with unilaterally elevated renal venous plasma renin activity. Therapeutic decompression of the cyst produced normalization of blood pressure. As documented in this and other reported cases, selective renal vein renin determinations have great potential applicability in the diagnosis of ischemia secondary to unilateral renal lesions other than main-stem renal artery stenosis. Dr. Robert E. Whalen permitted the use of his patient for this report.
14 Stockigt, J. R., Collins, R. D., Noakes, C. A., Schambelan, M. and Biglieri, E.G.: Renal-vein renin in various forms of renal hypertension. Lancet, I: 1194, 1972.
15 Stockigt, J. R., Hertz, P., Schambelan, M. and Biglieri, E. G.: Segmental renal-vein renin sampling for segmental renal infarction. Studies in a hypertensive patient. Ann. Intern. Med., 79: 67, 1973.