Surgical management of renal hypertension

Surgical COMBINED

Management

of Renal

EXPERIENCES AT THE MASSACHUSETTS MEMORIAL PETER BENT BRIGHAM HOSPITALS H. SMITHWICK,

of

From tbe Department Surgery,Massachusetts Memorial Hosaitals and Boston Universitv School of Medicine. Boston University Medical Cente;, and from* tbe Depart: ments of Urology, Surgery and Patbology, Peter Bent Brigbam Hospital and Harvard Medical School, Boston, Massachusetts. Tbis work was supported in part by Research Grant H-4635. (Cl) from tbe National Institutes of Healtb, United States Public Healtb Service, Wasbington, D. C., and by a grant from tbe Trustees under tbe wills of Charles A. King and Marjorie King.

intravenous urography, Ir31 renograms, differentia1 renaI function studies and aortography, have combined to make it possibIe to separate patients with this form of hypertension from the much Iarger hypertensive popuIation as a whoIe and aIso from another reIativeIy smaIl group of patients having hypertension of adrenal origin. In recent years, a great deaI of emphasis has been pIaced upon the fact that Iesions of the renal artery or. its branches, by contrast to parenchyma1 disease, are responsibIe for a high percentage of cases. AIso, patients in whom hypertension deveIops before they reach the age of thirty-five or after the age of fiftyfive, or who have hypertension of sudden onset especiahy after flank pain or which suddenIy progresses at any age are particuIarIy apt to have a renaI vascuIar Iesion. On this basis some clinics have adopted a pohcy of obtaining renaI arteriograms on al1 patients faIIing into these categories. The incidence of renaI vascular Iesions is high, being 25 per cent or more, among such patients. Other chnics are performing divided function studies of the two kidneys in a11 hypertensive patients but especiahy for acceIerated hypertension. From those having vascuIar Iesions certain patients who appear most amenable to direct surgery of the renaI arteries have been seIected for operation. Some large series of cases have been deveIoped in this way, in which some form of direct surgery was performed in virtuahy every patient with a high percentage of early favorable responses (65 to 80 per cent) and in which nephrectomy was rarely performed. The forty-seven patients under discussion in this report were cuIIed from a very Iarge group of hypertensive patients whom we be-

with the surgical management of hypertension of renal origin are summarized in this report which deals with twentysix patients operated upon at the Peter Bent Brigham HospitaI and twenty-one at the Massachusetts MemoriaI HospitaIs. AI1 but four of the patients (fohowed up for twelve, nine, eight and eight years, respectiveIy) were treated during the past five years. One patient in the Massachusetts Memorial HospitaIs’ series was operated upon at the Providence Veterans Administration HospitaI. These two institutions have a combined surgical residency program. Certain detaiIs of each of these forty-seven cases are summarized in TabIes IA, IB, IIA, IIB, IIIA and IIIB. The patients from the Peter Bent Brigham HospitaI are numbered and those from the Massachusetts MemoriaI HospitaIs are Iettered. The two series are surprisingly simiIar as to methods of study, type of patient material, method of treatment and resuhs. The diagnosis of hypertension of renaI origin has been made much more frequentIy in recent years than formerIy. The studies of Howard et a1. [I] have provided the recent stimuIus in the Iast ten years to physicians to study their hypertensive patients for possibIe renaI vascuIar disease. Certain cIinica1 characteristics and various heIpfu1 diagnostic procedures, such as XPERIENCES

American

Journal

AND THE

M.D., ROBERT C. NEWTON, M.D., DIANE H. CROCKER, M.D. AND J. HARTWELL HARRISON, M.D., Boston, Mussachusetts

REGINALD

E

Hypertension

of Surgery,

Volume

x07.

January

1964

104

Surgical

Management

of Renal Hypertension

‘I-ABLE

IA

GROL

Excc4lcnt 31, F Esccllent ~ 33, hl Excellent Excellent Excellent E~crIlent Excellent Excellent Excellent Excellent Excellent Excellent Improved Improved

~

Improved Improved Improved Failure

22, 1; 68, hl 24. F 37. kl 47. 21, 49, 38, 30, 52, 54, 20,

F hl A1 21 F n1 hl F

33, 51, 41, 31,

F Al F F

Unkno\\-n 6

I

I:.

/

I

6

160/130

130/w

I75/IO5 180/l00

I20/80

220/I

3 4 4 yr. 5 Yr. I7 Yr. I I5 Yr. 18 II yr. I8

I95/‘23 216/122 2I3/I3o 195/I24

Ncphrectomy Nephrectomy Nephrectom? 1Nephrectomy Nephrectomy Nephrectomy Nephrectom! Nephrectom! Nephrectom> Nephrectom? Nephrectomy Nephrectomy Nephrectomy (a) Tenon@ patch (b) Nephrectomy Nephrectomy Nephrectomy Endarterectomy Nephrectomy

20/70 13o/80 I 08/72 I4o/9o I40/80 I40/90 14o/9o 13o/9o 15o/9o r42/88

210/12j

23o/ 130 216/131 276/I 53 180/120 166/113 253/‘4I 290/16o 172/130

I

I

10

r9o/rr5

6 I4 18

1’

r80/120

165/I IO 150/100

I 60/90 I70/105 240/120

-I

* Numbers

= Peter

Bent

Brigham

Hospital;

letters

= Massachusetts

TABLE

hlemorial

Hospitals.

IB

GROUP

I Patholorr

Other Preoperative Data Cax’

Length of Kidney [cm.)

Result1

Parenchyrna

Length (cm.1

Puterio.

hfarrt

gram

I 2 ;

ICxcellentII

4 12 0 I1 3

I2 5

12

9 5

103 83

Ii.2 II 0

13 0 13 0

bx 2.0

11’ b 9.5

1G 127

1 I’.;, 11.5 IO 5

ii9 130 160 I29 104

9.5

5 8

Excellent I Excelknt : Excellent ~Excellent ExcPllent

9 B I, C I

Excellent ‘Excellent Excellent Excellent Excellent

11.5 t5 7 12 6 12 2

9.Y t7 7 14 3 I3 i

t2 0 ti 15

Excellent Improved

11 6

13 6

20

:

1.6

0 0 : 0

False 0 0 False 0

.l’. 2 0.5 0.5

* Numbers = Peter Bent Brigham HospIt%1; 1C:tters= i Measurementsare of c&weal span.

I10

130 90

95 10 5 12.0

135 124 188

11 5

106

Massachusetts

Memorial

‘05

Hospitals.

+I

0

Hypoplasia + Hypoplasia

+I + Thromhosed AllWySlll Hypoplasia + I + HypCIplZ& Hypoplasia Hypoplasia + Sclerosis Hypoplasia 0 Thrombosed Aneurysm + :I+

0 0 0

I

+ (I 0

0 0 0

Smithwick,

Newton,

Cracker

TABLE

and Harrison

IIA

GROUP II

-

-

-

BIood Pressure Known

Result

4s (yr.1 Duration and Sex

(mo.1

Preoperative (mm. Hg)

Postoperative (mm. Hg)

AntihyperDrugs

Operation 1IntervaI (yr.1

_ExceIIent ExceIIent ExceIIent ExceIIent ExceIIent ExceIIent ExceIIent ExceIIent ExceIIent ExceIIent

54> M 49, F 21, F 42, F so, F 50, M 65, M 47, F 34, M

ExceIIent ExceIIent Improved [ Improved [ Improved I

34, 53, 48, 50, 42,

FaiIure

41, F

16, F

__

r5 I2 16 6 Unknown 6 6 Unknown 3 yr. 2

F M F F F

3 4 3 I5 I8

160/130 I90/I IO 230/i IO 200/150 220/130 240/100 220/130 210/I IO I9o/I4o I9I/I32

Y’. yr. yr. Y’. yr.

I yr.

‘30/95 I IO/70 I 20/84 I I o/80 130/80 I 15/80 I IO/go I IO/80

210/140

120/80

236/I36

r3o/9o r74/rro r9o/9o

228/r35 237/r2r 200/140 220/I 20

Vephrectomy Vephrectomy Vephrectomy Vephrectomy Vephrectomy Vephrectomy Vephrectomy Vephrectomy Vephrectomy :a) SpIenorenaI 6) Nephrectomy Vephrectomy Vephrectomy Vephrectomy Vephrectomy Zxc. aortic aneurysm + nephrectomy Vephrectomy

r 3o/9o I ra/ao

150/I

IO

ZOO/I

IO

IO II

0

0

13 14 15 17 18

0

0 0 0

0

19 20 g

0 0

0

k I I2 m n

0 0

Y + -

16

* Numbers = Peter Bent Brigham HospitaI; Ietters = Massachusetts MemoriaI HospitaIs.

-

TABLE

IIB

GROUP

IIA Pathology

Other Preoperative

I_

Data

-

-

-

(cm.1

HOW&Xl ,d Test

Difference

Art&warn

1Length

Weight

(cm.1

(gm.1

-

14.0 13.5 13.5 10.5 10.3 10.0 12.6 t8.5 10.7

9.0 11.0 10.3 13.6 15.0 14.0 14.0 t6.8 13.6

14.2 11.0

5.0 2.5 3.2 3.1 4.7 4.0 2.6 t1.7 2.9

:

! 0 0

:

:

BranchRs

1

I nfarct

c

.

10.0 8.5 11.2 . .

4.0 8.5 7.5 8.2

: 0 0 0 Jnsatisfactory

-

.. -

Memorial

106

Hospitals.

+ 0 z Hypoplasia Hypoplasia

tis

0 0 0 0

+++ : 0 0 0 0

: 0 + 0 0 0 Hypoplasia

+:+ 0 0

: ::

: 0 0 0

+I 0 Hypoplasia

::

! 0

+&?+

t!+ t++ 0

+q, LR: R. R. L.

-

Py&I lephri-

_-

L. 1,. L. R. R. R. R. L. R.

52 53 67 79 52 80 128 160 80 95 20 62 ... 58 64 85

! 0

Numbers = Peter Bent Brigham Hospital: letters = Masseehusetts t Measurements are of calyoeal span (renal cyst).

l

-

Side

__ 9.0 7.0 9.5

0

4.7 6.0

-

i

: *

: 0 0 1Jnsatisfaa + 1Jnsatisfa Negati +

Parenchyma

_-

I lrtery .-

I 1 I I I I I I I I I I I I I I

I

Renal

Length of Kidney

10 11 13 14 15 17 18 19 20 J k L 12 m n 16

-

-

Intravenous Pyelogram

Right

(Ease *

1tens&

-

:

:

:

: +

: 0

: 0 -

:: ++ -

z + -

Surgical

Management

of Renal Hypertension

Y‘ABLE

1Il.t

GROUP

III

BIood Pressure fiesuft

! Age (yr.)

! and sex

~-/

I

I

; Antihypu-

Known Duration j (~r.1

i

Operation

/

ten&c I )rugs

!cast*

i__~ _

__ Grc,uj 0 III

Excellent EsceIlent Excellent ExcrfIent Improved Improved Improved Improved I mproved Operative death

58, 60, 35, 52,

M

32,

hl

18 mo. * mo. 2 mo.

hI hl F

2 1

56, F

mo.

Unknown I

45, F 48, F

IS 4 5 18 mo.

230/110 220/I IO

124/70 I zo/go

214/134 160/120 160/100 165/120 2r3/‘05 220/I 20 230/120 220/l 20

142/g8 ro5/80

r

mo.

22

8

I&/@

150/100 114172 177/100 200/100

20 mo. 3x5 3 ‘uj

I

Ncphrectomy Nephrectomy Nephrectomy Nephrectomy ( Nephrectomy Nephrectomy Nephrectomy Nephrectomy Nephrectomy Nephrectomy (died on 5th day postoperative)

0

I22

24 0 t

0

0 0 ; +

,f” /

q

0

r S 21

0

25

0

Group IV EscelIent

63, F

EsceIlent

58, hl

Improved

Unknown 2 IO

175/80

I 20/80

3

270/100 210/140

I 20/80 r58/81

1;;

partial

26 @;$;;;~~ztorny

‘I u

45, M

sympathectomy decapsulation

I * Numbers

Endarterectomy, nephrectomy

+

= Peter Bent Brigham HospitaI; Ietters = Massachusetts

Iieve to be more representative of the hypertensive popuIation as a whoIe than those having certain cIinica1 characteristics referred to. On this basis the incidence of renaI hypertension wouId be Iess than I per cent. In making the diagnosis, in addition to having in mind that hypertension in any patient may be of renaI origin, particuIar emphasis was pIaced upon intravenous urography as the most universaIIy avaiIabIe screening test and the 1131 renogram as it became avaiIabIe to us as another screening test. AIso, it has been noted in the Massachusetts MemoriaI HospitaIs’ experience and previously reported that in untreated patients with renaI hypertension, postura1 hypotension was found in about haIf the patients in contrast to its presence in about IO per cent of patients having so-caIIed essentia1 or maIignant hypertension. If as a consequence of such information a suspicion existed that the hypertension might be of renaI origin, definitive tests were empIoyed. In both series, differentia1 renaI func-

Memorial

HospitaIs.

tion tests were used more frequentlv and, in most instances, prior to renaI arteriography. Rena1 arteriography was empIoyed Iast and Iess frequently than any other method of study. A study of the six tables referred to indicates that hypertension was of renaI vascuIar origin in go per cent of the combined series of cases. However, the nature of the Iesions was such that direct vascuIar surgery was rareIy found to be feasibIe at expIoration, and nephrectomies were performed in forty-five of forty-seven patients. The operative mortality was low, being 2 per cent. The incidence of exceIIent results as judged by the hIood pressure response was 64 per cent, of improvement 30 per cent, and of faiIures 4 per cent. One patient (Case L, Group IIA) with an exceIIent bIood pressure response died three and a haIf years after operation of a cerebrovascuIar accident. Another patient (Case m, Group IIA) classified as improved died two and a half years after operation of pneumonia. The over-all results 107

Smithwick,

Newton,

Cracker

and Harrison

TABLE IIIB GROUP Intravenous Pyelogram

Case’

Result

Other Preoperative

III

Data

Pathology

Length of Kidney

Renal

(cm.)

IL”

Artenogram

Howard Test

Differ_Rmxram

Length (cm.)

Weight (pm.)

Parenchyma

Side

Group II1 22 24 0

Excellent Excellent Excellent

t

Excellent

23 P 9 r 8 21

Improved Improved Improved Improved Improved Operative

0 0 0

5.4 3.7

13.7

14.2 10.0 15.5 a.5

8.5 15.5 9.5 11.7

5.7 5.5 6.0 3.2

8.0 9.0

Unsatisfactory

+

9.0

64

+ 0 Unsatisfactory Negative

0 0 0 0 0 0

6.0 9.0 7.5

28 49 40 42 53 53

:

8.0 7.5

-

Grade

25 26

u

.. . ..

0 :

0 0

0 0 0

I

Solitary kidney (r) Aneuric 0

-

I-hromhosed + Aneurysm Hypoplssia + Sclerosis 0 Hypoplasia Hypoplasia Hypoplasia Hypoplasia

1

0

+ f 0 0 0

0 0

iTI+ 0 ++ ++ +++ 0 +:+ 0 0

+“+

-

t++ t++ t++ 0

IV

!

+

:

* Numbers = Peter Bent Brigham Hcapital; letters = Massachusetts Memorial Hospitals.

normaI, and the smaIIer kidneys had no function as judged by Diodrast excretion. In Group IV biIatera1 depression of renaI function was present. One of the three patients in this category had a soIitary kidney. AI1 of the original hIms were reviewed for size and function of kidney. In cases in which measurements are not given, the fiIms had been Iost or destroyed. In those cases, judgment as to cIass&cation had to be based upon the origina x-ray report and the Iength and weight of the kidney according to pathoIogic reports.

compare very favorabIy with those of other series of surgicaIIy treated patients. It is our impression that if patients with renaI hypertension are seIected from a representative cross section of patients with hypertension rather than from those having certain cIinica1 characteristics and arteriographic findings, nephrectomy wiI1 often be necessary and direct vascuIar surgery feasibIe in a much smaIIer percentage of patients than in series seIected primariIy on the basis of arteriography. The forty-seven patients under discussion were divided into four groups on the basis of intravenous urography. The primary consideration was the comparative over-a11 Iength of the kidneys. Rena1 function as judged by the excretion of Diodrast@ or renographin was aIso utilized in defining the groups. Group I contains those cases in which the difference in Iength of the kidneys did not exceed 2 cm. Also, renaI function was norma biIateraIIy as judged by Diodrast excretion. In Group II the difference in Iength exceeded 2 cm. The function of the Iarger kidney was norma and that of the smaIIer kidney varied from norma to sharpIy reduced as judged by Diodrast excretion. In Group III the difference in Iength aIso exceeded 2 cm. The function of the Iarger kidneys was

CASES

IN GROUP I

There were eighteen cases in Group I. Certain information about each is given in TabIes IA and B. They are arranged according to the effect of operation upon the bIood pressure Ievel. The resuIts were exceIIent in twelve cases. HaIf the patients were under forty years of age. Hypertension was of short known duration in the great majority of patients and not over five years in any. Of the five patients cIassified as improved two were under forty; however, what may be more important from the viewpoint of prognosis was hypertension of Iong duration, more than ten years, in three cases. With regard to kidney size the difference in 108

SurgicsI

COXl’AKTIVE

LENGTH

AND

WEIGHT

Management

OF

KIDNEYS GKOSS

of Kenal AS

Hypertension

JUDGED

I Average

Uninvolved

Kidney

Length

Involved

BY

INTRAVENOUS

ClIOGK4PHY

AND

1’ATHOLOG.x

I

Average

I D’ffI erencein

Lfngth

twcen Roentgenogram

(cm.) bevs.

Kidney

,

Iength as judged by roentgenograms varied from 0.8 to 2 cm. in ten patients in whom the invoIved kidney was smaIIer. In two patients the involved kidney was Iarger by 0.5 cm. In one of these, resuIt was cIassified as improved; the other was regarded as a failure. In the Iatter case, the invorved kidney was not only larger but the uninvoIved kidney was unusuaIIy smal1 measuring 12 cm. Thus, hypertension of long known duration of over ten years, an involved kidney being the Iarger and the uninvolved kidney unusuaIIy small, may be factors which might Iead one to expect Iess than an exceIIent resuIt. Some additional information regarding kidney size is contained in TabIe IV. As judged by intravenous pyeIograms, the average Iength of uninvolved kidneys in Group I was 13.2 cm. The involved kidneys averaged 12 cm., a difference in length of 1.2 cm. The average length of the kidneys removed was 10.6 cm. according to the pathologic reports. This measurement averaged 1.4 cm. less than the Iength according to the roentgenogram. The average weight of the removed kidneys was I 19.8 gm. The weights varied from 83 to 188 gm., and only four kidneys weighed less than IOO gm. As has been previousIy stated, the suspicion that hypertension of renal origin might be present was first aroused from the cIinica1 data and the results of intravenous urography. Supporting evidence in seventeen of the eighteen patients was obtained from further studies. 1131 renograms were performed in ten cases, Howard tests in fifteen and renaI arteriography in six.

More than one of these additiona tests were performed in eIeven patients. As indicated in TabIe IB, some Iesion of the renaI artery or of its branches or both was found in every patient. OnIy one kidney showed minimal evidence of pyelonephritis, not suff~cient to have been a causative factor. The renal artery only was invoIved in Cases I, 2 and i, by foca1 stenosis in the first and focal scIerosis in the other two. A branch Iesion only, a thrombosed aneurysm, was noted in Case 6. In the remaining patients some abnormality of the renal artery and one or more of its branches was found. Of particular interest are eight patients with hypopIasia of the renal artery and its branches. In six the right kidney was invoIved. In seven no organic pathologic condition of either the main arteries or branches was found. In one there was diffuse sclerosis of the artery and its branches. These patients had very narrow arteries and branches and direct surgery was not judged to be feasible. (Fig. I.) Minimal evidence of parenchyma1 damage was present in these patients. The remaining six patients had Iesions of the main artery and branches. Case 5 had focal intimaJ fibrosis of the main artery and diffuse intimaI fibrosis of one branch. Case a had focal medial fibrosis of the artery and diffuse media1 fibrosis of one branch. In Case 7 the renaI artery contained a pIaque and a thrombus, was kinked and the branches showed thrombosis. Case cl had diffuse intima1 fibrosis of the artery and diffuse intimal fibrosis of the branch to the lower pole. Case e had nearly compIete arterioscIerotic occIusion

Smithwick,

Newton,

Cracker

and Harrison

in the hope that if this was not effective, it would render the patient much more responsive to antihypertensive drugs, as often is the case. AI1 drugs had been omitted for one month prior to admission for splanchnicectomy. BIood pressure studies prior to operation reveaIed that the average of five readings in the horizonta1 position taken at one minute intervaIs was z16/131 mm. Hg. The average of five readings taken in a simiIar manner in the upright position was 174/122 mm. Hg. In other words, the patient had postura1 hypotension. Since it has been noted in the Massachusetts MemoriaI Hospitals’ experience that about haIf of the patients with renaI hypertension have systolic and diastoIic pressures which, when taken as previousIy described, both average I mm. or more Iess when standing than when Iying down, the finding of postura1 hypotension in this patient aroused our suspicion that a renaI cause might exist. IncidentaIIy, these same findings hoId true for patients with pheochromocytomas or aldosteronism. The intravenous pyelograms were reviewed. It was found that none of the fiIms outIined the upper Iimit of the right kidney cIearIy; therefore, it was not possible to measure its over-all Iength. This brings out the importance of measuring the Iength of the kidneys in hypertensive patients. If the fiIms do not permit this, Iaminograms shouId be obtained at the time of intravenous urography. The Iength of the caIycea1 span is an alternate measurement. This usuaIIy shows Iess of a difference than the over-al1 Iength. In this case, the caIycea1 span on the right side was 5.7 cm. and on the Ieft 7.7 cm. Since this meant a definite difference in over-a11 Iength, a Howard test was performed. The result was strongIy positive. We planned then to obtain renaI arteriograms. At this point, encephaIopathy deveIoped with convuIsions and coma. Nephrectomy was performed as an emergency procedure. The patient’s bIood pressure, which was extremeIy high prior to operation, feI1 to norma during operation and has remained SO for five years. Blood pressure Ievels prior to operation and in the earIy postoperative period are shown in Figure 2. The kidney weighed 130 gm. FocaI media1 fibrosis of the dista1 renaI artery and diffuse medial fibrosis of one branch were present, which were not amenabIe to direct surgery. Even if they had been, the condition of the patient made nephrectomy the onIy choice. The parenchyma1 changes consisted of mild ischemic tubuIar atrophy. There was marked hypertrophy of the juxtagIomeruIar apparatus.

FIG. I. (Case b, Tables IA and B.) Arteriogram taken at expIoration showed a smaII hypopIastic, patent right renaI artery which divided into two very smaII branches. The pulsations were decreased but present. The Ieft kidney was enIarged. Right nephrectomy was performed. There was no pathoIogic disease of the renaI artery or its branches or of the parenchyma.

of the artery at its origin, with poststenotic diIatation and arterioscIerotic occIusion of the upper branch with infarction and atrophy of the upper haIf of the kidney. Only in Cases 7 and i was direct surgery judged to be feasibIe or, with one or two exceptions, to have a sufficient chance for success to warrant it. In these cases the poor genera1 condition of the patient did not justify direct surgery even though there was a reasonabIe chance that it wouId be successfu1. Brief comments on severa cases wiI1 serve to emphasize certain points. Case a, in TabIes IA and B, was a twenty-one year old man who had severe hypertension of eighteen months’ duration. He had been treated medicaIly for a year during which he did not respond satisfactorily to large quantities of various combinations of antihypertensive drugs. (Fig. 2.) Prior to treatment, studies reveaIed no evidence of hypertension of renal origin. BIood urea nitrogen was normal as was the phenolsulfonphthalein output. An intravenous pyeIogram was interpreted as normaI, and no evidence of aIdosteronism was present. Because the hypertension was so refractory, the patient was referred for splanchnicectomy

Case e (Tables IA and B) was a fifty-one year old man with severe hypertension of short duration, refractory to medication. He had retinitis and had recovered satisfactoriIy from a recent cerebrovascuIar accident. The right kidney was 1.2 cm. shorter than the left. The function of both kidneys was 110

Surgical

Management

of Renal

Hypertension

160

k-E--

IO

40

20

50

60

WEEKS

‘DAYS’

FIG. 2. (Case a, TabIes IA and B.) BIood pressure responses in a twenty-one year old man treated intensiveIy for severe hypertension of the malignant type for about a year prior to nephrectomy with antihypertensive drugs which were not effective. The diagnosis was suspected because of posturat hypotension which persisted after drugs had been omitted for one month. The resuIt of a Howard test was positive. Emergency nephrectomy was performed because of encepha1opath.y with convuIsions. BIood pressure continues to be normal five years after nephr&tomy.

had been performed eIsewhere. This had IittIe effect upon the bIood pressure. In 1951 one adrenal gIand and haIf of the other were removed. After this operation the bIood pressure was more responsive to antihypertensive drugs and for seven years remained in a reasonable range, 160-200/108-r 13 mm. Hp. During the two years prior to the admission under consideration, the bIood pressure IeveIs rose considerably and evidence of cardiovascuIar disease increased despite the use of large amounts of various antihypertensive drugs. She was admitted for study to determine if evidence of a renaI factor couId be found. BIood pressure was zr3/130 mm. Hg. An intravenous pyelogram showed norma function bilaterally. The right kidney measured 13.8 cm. and the Ieft, 13.3 cm. On this basis suspicion was directed toward the Ieft kidney. An Ir3r renogram revealed the function of the left kidney to be retatively less than that of the right. The difference was considered significant. A Howard test was performed. The resuIt was strongly posi-

otherwise norma and the Ieft kidney was Iarge, measuring 14.4 cm. The result of a Howard test was strongIy positive. At operation the aorta was extremeIy scIerotic and the right renaI artery almost occluded at its origin with poststenotic dilatation. The upper branch was thrombosed and the upper portion of the kidney infarcted. Direct surgery consisting of a bypass graft to the aorta together with partiaI nephrectomy might have been attempted. Under the circumstances it was thought wiser to perform nephrectomy. The patient is ciassified as improved. His bIood pressure is rgo/go mm. Hg five years after operation, and he responds readiIy to a smal1 amount of one of the rauwoIfia derivatives. The kidney weighed 188 gm. and showed evidence of infarction and extreme ischemic tubuIar atrophy. Case i (TabIe IA and B) was a forty-one year old woman with hypertension of eleven years’ known duration. In 1949 IumbodorsaI spIanchnicectomy III

Smithwick,

Newton,

Cracker

and Harrison

feIt much better. There has been regression of cardiovascuIar changes and the bIood pressure has remained in the vicinity of I~O/IO~ mm. Hg with the assistance of a smaI1 quantity of antihypertensive medication. She is classified as improved. This seems to be an instance when the larger kidney was impIicated. The intravenous pyeIogram and the renogram directed attention to the smaller kidney; however, the Howard test and the arteriogram indicated conclusively that the Iarger kidney was involved. Case h (TabIe IA and B) was the one faiIure among the cases in Group I. The patient, a thirtyone year oId woman had hypertension of eighteen months’ known duration. The bIood pressure was rg5/ 124 mm. Hg in the Iying position and 160/r 19 mm. Hg in the standing position. She had Grade 3 eyegrounds, an abnormal electrocardiogram and a norma sized heart. The intravenous pyeIogram was within normal limits with the exception that the right kidney was 0.5 cm. Iarger than the left. Her phenoIsuIfonphthaIein output was 40 per cent in fifteen minutes and 85 per cent in two hours. Because she had postural hypotension, it was thought advisable to pursue further the possibility of a renaI factor. A Howard test was performed and the resuIt was positive. The volume of urine from the right kidney was 24.7 cc. and from the left, 34.2 cc. The sodium concentration on the right was 3 mEq. per liter and on the Ieft 66 mEq. per liter. An aortogram outlined a normal Ieft renaI artery and branches. The right renaI artery was not visuahzed at aI1. At exploration the right kidney was normal except for a very Iong narrow renal artery which divided into very small branches some distance from the kidney. The pulsations in the artery and branches were very faint. The Ieft renaI artery was Iarge and puIsated we11 and the kidney appeared normal. Right nephrectomy was performed. The kidney weighed 106 gm. No pathologic condition of the artery or branches was found and onIy miId evidence of ischemic tubular atrophy was present. The bIood pressure mm. Hg three years continues elevated at 240/120 after operation, despite the use of large amounts of various antihypertensive drugs. The evidence for renaI hypertension seemed good: postura1 hypotension, a positive Howard test and arteriogram. On the other hand, the invoIved kidney was sIightIy Iarger and the uninvolved kidney was unusuaIIy small, measuring IZ cm. in length. This was with one exception the smallest uninvolved kidney in Group I, the exception being Case g; however, in that case the uninvoIved kidney was larger. One shouId probabIy be suspicious of the outcome when the uninvoIved kidney is the smaIIer kidney and has not shown some evidence of having hypertrophied. In the previous case (Case i), aIthough

FIG. 3. (Case i, Tables IA and B.) This retrograde femoral arteriogram reveaIs obstruction of the right renal artery near its origin and a normal left renal artery. The right kidney was sIightIy Iarger than the Ieft (the uninvoIved kidney), an unusual situation. This directed attention to the Ieft kidney as did the I’al Diodrast renogram. The Howard test was aIso positive

for abnormahties on the right side. This case is commented upon to caI1 attention to the fact that whiIe screening tests may indicate a difference between two kidneys (which is a11they are supposed to do), definitive tests, differential renaI function and arteriography are needed to make an accurate diagnosis. but indicated that the right kidney rather than the Ieft was the cause. An aortogram reveaIed a normal Ieft renaI artery and branches. The right renal artery was completely occIuded about I cm. from its origin, confirming the evidence obtained from the Howard test. (Fig. 3.) At expIoration the right kidney was supphed by three good sized arteries arising separately from the aorta. These pulsated very weI1. In addition the usua1 renaI artery was compIeteIy thrombosed over a distance of about 2 cm., starting about I cm. from the aorta. The renaI artery and its branches beyond this point were patent but did not pulsate. Endarterectomy was performed. Since operation she has

tive

112

Group II contains sixteen cases. The resuIt as judged by blood pressure responses was regarded as excelIent in twelve and improved in three. There was one failure. Certain data concerning each case are given in Tables IIA and R. The cases are arranged according to the elect upon blood pressure. Four patients were under forty years of age among those hav.ing excellent results, or a third by contrast to a half ofthe cases in Group I. As with cases in Group r, regardIess of their age, hypertension was of very short known duration in the great majority and not over four years in any case. AI1 of the improved patients were over forty years of age. Two of five patients in this category were under forty years of age in Group r. The patient considered a, faifure was forty-one years old. The difference in kidney size by definition exceeded 2 cm. in every patient. This varied from z._; to 6 cm. The involved kidney was the srnaher in al1 patients. As indicated in Table IV, the average length of the uninvolved kidneys as judged by roentgenograms was 14.1 cm. and of the involved kidneys 10.3 cm., a diEererence of 3.8 cm. The uninvoIved kidneys were on the average 0.9 cm. Iarger than those in Group I, while the invoIved kidneys were 2.3 cm. smaIIer than those in Group I. This suggests that the diiference in the size of the kidneys is the result, in part, of enlargement of the uninvolved kidney but LO a greater extent a decrease in size of the invoIved kidney. As judged by the pathologic reports, the removed kidneys averaged 8.3 cm. in length, z cm. Iess than the Iength according to roentgenograms. The average weight of the removed kidneys was 62.3 gm., about half that of the kidneys in Group I. As indicated in TabIe IIB, the length of the uninvolved kidneys in Group 11 varied from r3.f to i7 cm. with the exception of Case 12. In that instance it was 12 CM., which was definiteIy out of Iine with the group as a whole, ‘This appears to indicate that in this patient, the uninvolved kidney had not enIarged and might be the reason for the improved rather than excehent resuIt. In Case n, in which the result was graded as improved rather than excellent, the result of the Howard test was negative. In retrospect, these seem to be the

only two tindings which might have led one to suspect Icss than an excellent result. ‘I-here is no obvious explanation for the failure in Case IA. The Iength of the invofved kicine~s in Group II as judged by roentgenrtgram varied from 9 to 12.6 cm.; when judged by the pathologic reports, it varied from I 1.2 to 4 cm. and was much more comparable in size tct that of the kidneys in Group III than in Group 1. By definition, the function of invoIvecl kidneys in Group II as judged by the excretion of Diodrast varied from normai to markedlv impaired, whiic kidneys in Group RX had no function and those in Group I had normal function. Irs’ renograms were performed in six pntients in Group II, Howard tests in thirteen and arteriograms in four to suppIement the ciinicat data and pyeIograms. One renogram was within normal limits and the result of one Howard test equivocal (Case r3f when in retrospect one would expect them to be abnormaf. In Case r3 the renai arteriogram gave positive results. Two Howard tests were unsatisfactory because of an inadequate amount of urine from the involved kidney. It is not worthwhile to perform differential renaI function tests when the function of one kidney is absent or poor as judged by intravenous urography. The result of one Howard test was negative (Case n). In this case a combination of renaI arterial, branch and parenchymal disease \vas present which may account for it. The renai artery or its branches were abnormal in alI but one case (Case kj. The patient had advanced pyelonephritis. The kidney was 4 cm.. in Iength and weighed 20 gm. Hypopfasia of the renal artery and its branches was secondary to the renaf atrophy caused by parenchymal disease. In Cases 13~ 14 and 20 primary hypoplasia of the renal arteries and branches was present simifar to that of the patients noted in Group I. In two of these pa.tients the right side was involved. N5 pathoIogy of the arteries or branches was found and the parenchymal changes varied from none at aI1 to marked ischemic tub&r atrophy. In six cases (Cases 1t, I 5, I 7, 18, j and 16) the renaI artery only was involved. In Case r I, an embolic occIusion was present with evidence of parenchymaf inf&tion. in Case 15 there was media1 hyperplasia, In Cases r; ‘md r s8 an intimal pIaquc and stenosis were present, respective?y. The parenchymal changes in these varied from none ta moderate

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for occIusion of the artery and its branches. In Case IO thrombosis of the artery and branches was present with intimaI fibrosis of the branches. In Cases L, m and w, arteria1, branch and parenchyma1 disease were noted. There was diffuse arterioscIerosis of the main arteries and one or more branches in Cases L and n and foca1 arteriosclerotic occIusion of the artery and diffuse scIerosis of the branches in Case m. AI1 three patients had significant evidence of chronic pyeIonephritis as weI1.

FIG. 4. (Case L, Tables IIA and B.) Roentgenograms of the kidneys of this fifty-three year old man were regarded as not remarkabIe in 1956, despite the fact that the right kidney was some 4.3 cm. shorter than the Ieft. In 1957, about a year and a half Iater, the right kidney was a IittIe smaIler than previousIg and the left kidney was stiI1 much Iarger than the right and was hype;trophied. That the hypertension presumabIy was of right renaI origin wouId be quite apparent today (and shouId have been in 1956). The right kidney which measured 10.1 cm. by roentgenogram was 8.5 cm. in Iength when removed and weighed 62 gm. This case aI& ilIustrates the probabiIity that offending kidneys which are 10.0 cm. or Iess in length when associated with normaIIy functioning hypertrophied opposite kidneys can rarely be salvaged by direct surgery. Nephrectomy will usuaIIy be necessary.

In Case j arterioscIerotic evidence of &hernia. occIusion of the origin of the renaI artery was present and in Case 16, an intimaI pIaque was noted. The parenchyma1 changes were those of miId to moderate ischemic atrophy. In Case 19 a renal cyst was present which compressed the renaI artery which was otherwise normal. Severe parenchyma1 ischemic atrophy was present. In Case 12 emboIi were responsibIe

The patient in Case j (TabIes IIA and B) was a thirty-four year oId man with hypertension of short duration (two months). It foIIowed an episode of left flank pain with associated hematuria. Hypertension was severe, brood pressure measuring 191/r 32 mm. Hg. He had retinal hemorrhages and exudates and an abnorma1 electrocardiogram. The phenoIsuIfonphthaIein output was 30 per cent in fifteen minutes and 86 per cent in two hours. Nonprotein nitrogen was 40 mg. per cent. The intravenous pyeIogram showed a Iarge, normally functioning right kidney. The Ieft kidney was considerabIy smaIIer and excreted the dye poorly. On exploration the first centimeter of the left renal artery was completely occIuded by thrombosis. The artery and its branches were otherwise patent but without puIsations. The kidney Iooked very we11 except for its reduction in size. A spIenorena1 anastomosis was performed, which produced no effect on the blood pressure. Two weeks Iater nephrectomy was performed. BIood pressure feII to norma promptIy and is stiI1 norma twelve years Iater. The kidney weighed 95 gm. and showed sIight evidence of ischemic tubuIar atrophy. A kidney of this size with little parenchyma1 damage is probabIy we11 worth whiIe trying to save if the genera1 condition of the patient justifies the effort. Judging from the literature, about half the spIenorenaI anastomoses have been successful. It wouId appear that endarterectomy with or without a patch graft or an aortorena1 bypass graft is more IikeIy to succeed under the circumstances that prevaiIed in this case. Case L (Tables IIA and B) is instructive. The patient, a fifty-three year oId man, was first examined because of severe hypertension with beginning CardiovascuIar disease in ApriI 1956. CarefuI study was thought to reveal no evidence of a renaI or adrena factor. The kidney function was norma and the intravenous pyelogram was interpreted as within norma Iimits. He was pIaced on intensive antihypertensive drug therapy to which he did not respond. Seven months Iater spIanchnicectomy was performed. There was Iittle effect on the bIood pressure and he remained refractory

Surgical

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of Rend

Hypertension

to untihypcrtcnsive

drugs as well. He was rcadmitted for re-evaluation of the renaI situation in September 1957. The original pyelograms were rcviewcd and it was found that although the function was normal bilaterally, the right kidney was actually smatlcr than the left by 4.3 cm. and was I 0.7 cm. in length. The pyeIogram was repeated. It rcvealcd decrcascd function on the right. The right kidney was now 10.1 cm. in length. (Fig. 4.) In thr seventeen months between the two roentgenograms, the right kidney had decreased slightly in size and its function had deteriorated. The Ieft kidney measurrd 15 cm. originaIIy and 14.5 cm. on the second set of films. An 1’31 renogram was positive. A Howard test was unsatisfactory because of inadequate urinary flow. Nephrectomy was performed. The kidney weighed 62 gm. and was 8.5 cm. long. There was diffuse scIerosis of the artery and its branches. The parenchyma showed marked ischemic changes and advanced pyelonephritis as well. BIood pressure was 130/90 mm. Hg three years after nephrectomy. The correct diagnosis obviously should have been made originally.

CASES IN GKOUP III The ten cases in Croup III are summarized in Tables IIIA and B. In this group the uninvolved kidneys had norma function and the involved kidneys did not function as judged h,v intravenous pyelography. The involved kidneys were smaller than those in Groups I and II. There were four excelIent resuIts. One of these patients was under forty years of age, and in all the known duration of hypertension was short. The other nine patients were considerabIy older than the patients in Groups I and II. Five patients were classified as improved. In one of these the known duration of hypertension was fifteen years. One patient died on the fifth postoperative day of anuria caused by thrombosis of the remaining renaI artery. IL31 renograms were obtained in four patients; all showed positive results. Of five Howard tests, the results of two were positive, one was negative and two were unsatisfactory because of Iow voIumes. OnIy one arteriogram was performed and it was positive for abnormaIities. A Howard test is not necessary if one kidney is norma by excretory urography and the other kidney shows no visibIe evidence of excretion. However, uretera catheterization in such a case affords an opportunity to measure the function of the good kidney and, also, may show that the invoIved kidney is actualIy excreting urine aIthough with diminished function. Arteriography serves to demonstrate the vascuIar Iesion which in two of our patients was embolism and accompanying vasospasm. EmboIectomy and partial nephrectomy yieIded resumption of function of the solitary kidney in one of these. The arterial Iesion had been deiineated by arteriography prior to surgery. In addition to measuring the pressure gradient from aorta to renaI artery at surgery, arteriography is at times performed at the operating tabIe. (Fig. I.) As judged by the pyelograms (Table IV), the involved kidneys averaged 8.9 cm. in length and the uninvoIved kidneys, 13.7 cm. The corresponding measurements for kidneys in Group II were 10.3 and 14.1 cm., respectlveIy. It would seem that as the invoIved kidneys become progressively smalIer, the uninvolved kidneys do not enIarge further. As judged by the pathologic reports, the average lengths (8 cm.) and weights (55.5 gm.) of the removed kidneys in Group III were onIy sIightIy Iess than

The patient in Case n (Tables IIA and IIB) was forty-two years old at the time of nephrectomy. She was originaIIy studied for severe hypertensive cardiovascular disease, and splanchnicectomy was performed in 1945, when she was twenty-nine. She did very well untiI 1953, when her headaches recurred. Blood pressure was 200/132 mm. Hg at that time. She was pIaced on a Iow salt diet and given antihypertensive drugs to which she responded satisfactoriIy for about five years. Blood pressure then began to rise when she was in a horizonta1 position despite drugs, and increasing evidence of postural hypotension developed. An abdominal aneurysm also had deveIoped. Intravenous pyeIogram reveaIed prompt appearance of the dye and good concentration biIateraIIy; however, the right kidney was 9.5 cm. in Iength and the left was 14.2 cm. The resuIt of a Howard test was negative. The abdomina1 aneurysm was resected and replaced by a graft, and the right kidney was removed. There was arterioscIerotic narrowing of the renal artery with occIusion of the branch to the upper pole which was infarcted and atrophied. The kidney aIso showed chronic pyeIonephritis as well. It weighed 58 gm. and was 8.2 cm. in length. She has been well for four years, her bIood pressure being under better contro1 at 150/1 IO mm. Hg with the aid of smaI1 amounts of antihypertensive drugs. This is probabIy an example of essentia1 hypertension in a young woman in whom arteriosclerosis developed with the passage of time as evidenced by the aneurysm and scIerosis of the right renaI artery. Refractory renaI hypertension probably developed when the upper poIe of her kidney became infarcted. 115

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those of the kidneys in Group II, which measured 8.2 cm. and weighed 62.5 gm. The primary pathoIogic condition was advanced pyeIonephritis in four patients with secondary hypopIasia of the renaI arteries and branches (Cases p, q, r and s). The renal artery onIy was invoIved in Cases 22 and 24 by stenosis of the aortic ostium. The kidneys showed moderate to severe ischemic changes. In Case 23 a norma artery was present with narrowed Iumens of the branches. The other three patients had invoIvement of the renaI arteries and branches. A thrombosed aneurysm of the dista1 renaI artery with two thrombosed branches to the kidney was present in Case o. In Case t hypopIasia of the renaI artery and branches was present with scIerotic occIusion of the branch to the upper pole. In Case 21 intima1 ptaques were present in the renal artery with segmenta intima1 fibrosis in a11 branches. The parenchymal changes consisted of miId to moderate ischemic atrophy in a11 three, with evidence of infarction in Cases o and t, and with a moderate amount of pyeIonephritis in Case t as well. The Iength of the removed kidneys in Group III ranged from 6 to g cm. and the weights from 28 to 83 gm. The average Iengths and weights of these kidneys were onIy sIightIy Iess than those of the kidneys in Group II. When one considers that the kidneys in Group III were nonfunctioning and could not be salvaged, one wonders if the kidneys in patients in Group II with some function but of comparabIe size and weight are worth attempting to saIvage. Regardless of whether the pathoIogic disease is primarily arteria1 or parenchyma1, when a kidney atrophies to a certain point, its bIood supply does aIso. It wouId be heIpfu1 to be abIe to take a definite position on this point, since it is a Iess complicated procedure to perform nephrectomy by the usual approach than to perform Iaparotomy in the hope that one can saIvage a kidney when the chance of so doing is remote, and then proceed to perform nephrectomy the hard way. One can onIy suspect that if the measurements of the kidneys of patients who have responded we11 to direct surgica1 procedures as judged by the pyelograms were avaiIabIe in the literature, in the vast majority of successful cases, the involved kidney wouId be found to be onIy sIightIy smaIIer than the uninvoIved kidney, perhaps 3 cm. at most and 2 cm. or Iess as a rule. It seems to us worth whiIe to try to

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Iearn as much as possible from the evidence afforded by intravenous urography, since it is a reIativeIy innocuous and generaIIy avaiIable diagnostic and screening test. DifferentiaI renaI function tests and arteriograms are very useful; however, they are unpleasant ordeals for the patient and not without some hazard in the best of hands. They should be used when indicated but shouId not be performed unnecessariIy. SeveraI cases in Group III seem worth commenting on briefly. Case r, the patient mentioned in TabIes IIIA and B was forty-eight years old at the time of nephrectomy, but was first seen by us four years and four months previously. Studies revealed a blood pressure of 240/110 mm. Hg, Grade I eyegrounds, an abnorma1 eIectrocardiogram and norma heart size. The phenoIsuIfonphthaIein output was 35 per cent in fifteen minutes and 91 per cent in two hours. Intravenous pyelogram was interpreted as normal in every respect except for slight bIunting of the calyces on the right side. On sedation the bIood pressure feI1 to 120/80 mm. Hg. The resuhs of a Regitine test were positive. Urinary catechoIamines were normal. Laminograms of the adrena areas were negative for abnormalities. There was no evidence of aIdosteronism. Her symptoms were severe headache, fatigue and nervousness. She was placed on a medica regimen which eventually consisted of large quantities of several antihypertensive drugs. She was compIeteIy refractory to every conceivable combination and acquired additiona symptoms as a consequence of their side effects. Because she was so refractory to treatment, a renal factor was suspected and a Howard test performed after eight months of treatment. The resuIt was negative. BeIieving that a renaI cause had been excluded, splanchnicectomy was performed. She continued to be refractory to treatment which again included massive quantities of antihypertensive drugs. During the next three and a half years, evidence of cardiovascuIar disease graduaIly increased, especiaIIy in the retina1 and cardiac areas. BIood pressure remained in the range of 220-z32/120-ISO mm. Hg. Evidence of peripheral vascular disease developed with severe intermittent cIaudication on the Ieft side and loss of all p&es on that side except for a weak femora1 puIsation. Angina pectoris aIso became a probIem. She was readmitted for evaluation of the renaI area. An 1131renogram was positive for abnormalities on the right side. Intravenous pyeIogram revealed an enIarged normaIIy functioning left kidney and a smaI1 nonfunctioning right kidney. (Fig. 5.) The origina pyeIograms were reviewed. To our chagrin, they in fact revealed that there was a difference in the size of the two kidneys. On June 12, 1956, the

116

right kidney measured 12.2 cm. and the left, 14.5 cm. The films of September zz, 1960, showed that the right kidney measured IO cm. and the Icft 15.5 cm. The right kidmy had decreased in size I cm. Ncphrtcby 2.2 cm. while the Ieft increased tomy \vas performed. The pathologic report revealed that the atrophy was caused by severe chronic pyelonephritis. The bIood pressure since nephrectomy has remained in a mildIy hypertensive range, measuring 160/105 mm. Hg wrthout the aid of antihypertensive drugs. She is symptomatically much improved and certain evidences of cardiovascuiar disease have regressed. This cases emphasizes the importance of a carefui study of the information to be derived from intravenous urography. Case s (Tables IIIA and n), a lifty-three year old woman was managed well from the viewpoint of study in that after a period of faiiure of medical management when an intravenous pyelogram revealed a large normally functioning kidney on one side and a smalI nonfunctioning kidney on the other (Fig. 6), no further tests were performed, She did not have an Ir3r renogram, a Howard test or an arteriogram. On the other hand, she was not well managed surgically because despite the fact that the good kidney functioned normally and its ovcrhypertrophy) all length was 15.5 cm. (indicating and the nonfunctioning kidney measured 9.5 cm., Iaparotomy was performed in the hope that the kidney could be salvaged. The renal pedicle was atrophied and nepllre~tomy was performed. She had a chronic cough caused by cigarette smoking A secand eviscerated one week postoperatively. ondary closure was uneventful but would have been unnecessary if nephrectomy by the retroperitoneal approach had been performed in the first piace. This

brings us back to the question previousiy raised regarding the significance of the size of ar. involved kidney, whether functioning or not, and the surgical approach. This kidney weighed 53 gm. and was 8 cm. in length according to the pathologic rrport. Blood pressure was 105~80 mm. Hg lvithout the use of drugs one year later, and she t\as symptomatically improved. The patient in Case t (TabIes II~A and n] was the onIy patient in the entire series who had secondary aldostcronism in association with hypertension 01 renal origin. This case will be summarized in a dis-

cussion of aldosteron~sm by the samr authors another article in this Symposium.

in

FIG. 6. (Case s, Tables IIIA and B.) Hypertension refractory to antihypertensive drugs in a fifty-three year old female patient. ~oentgenograms revealed a marked difference in the size of the kidneys, with hypertrophy of the right (15.5 cm.) and atrophy of the left kidney (9.5 cm.). The left kidney was removed. It was 8 cm. in Length and weighed 53 gm. The atrophy was caused by chronic pyetonephritis.

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formed. A renaI biopsy showed Grade 3 arterioIar sclerosis. One year after operation he returned for a checkup examination. The eyegrounds were Grade 2. EIectrocardiogram was norma as was renaI function as judged by phenoIsuIfonphthaIein output. BIood pressure was r66/101 mm. Hg. He was on a Iow sodium diet without antihypertensive drugs. The situation remained essentiaIIy status quo for the next eight years. At this point he was referred back for study by his IocaI physician because of a recent exacerbation of hypertension within two months of having lost an important business account which was responsibIe for about haIf of his income. FaiIing vision was his chief compIaint. His eyegrounds showed two diopters of papiIIedema with hemorrhages and exudate. BIood pressure was 285/162 mm. Hg. EIectrocardiogram was abnorma1. The phenoIsuIfonphthaIein output was IO per cent in fifteen minutes and bIood urea nitrogen was 48 mg. per cent. An intravenous pyeIogram revealed normal sized kidneys with very poor function on both sides, especiaIIy on the right (the fiIms cannot be found). An I131 renogram indicated bilateral depression of renaI function, especiaIIy on the right side. The patient was discharged and pIaced on an intensive medica regimen of diet and drugs; he returned six months Iater for checkup examination. BIood pressure was 210/140 mm. Hg. Eyegrounds were Grade 3; eIectrocardiogram was abnormal. The phenoIsuIfonphthaIein output was 15 per cent in fifteen minutes and bIood urea nitrogen was 3 I mg. per cent; on the whole, this was an improvement. An aortogram showed poor visualization of the right renaI artery. (Fig. 7.) The Ieft renal artery and branches were seen. The proxima1 portion of the Ieft renaI artery appeared to be directed downward and posteriorly. On February 2, 1961, expIoratory Iaparotomy was performed. The Ieft kidney appeared to be a IittIe Iarger than the right one. Both renal arteries and their branches were patent but were involved in an extensive perivascuIar fibrotic process. VirtuaIIy no puIsation was noted on the right side. The proximal portion of the Ieft renaI artery puIsated we11 but was kinked downward and posteriorIy by an adhesive band with partia1 obstruction about 3 cm. from its origin. From that point distaIIy, pulsations were poor and a periarteria1 fibrotic process simiIar to that on the right side but not quite as extensive was found. The entire extent of both renaI arteries and their branches were freed by removing their adventitia1 Iayers. This was tantamount to periarterial sympathectomy. After this was accompIished, there was exceIIent puIsation of both arteries and a11branches. Both kidneys were decapsuIated in the hope that

FIG. 7. (Case u, TabIes IIIA and B.) This retrograde femoral arteriogram reveals abnormal renal arteries with virtuaIIy no fiIIing on the right and some Ming on the Ieft. The patient had severe rapidIy progressing hypertensive disease with nitrogen retention. Both renaI arteries and their branches were invoIved in an extensive periarterial fibrotic process and puIsated very poorIy. BiIateraI periarteria1 sympathectomy was performed with decapsuIation of the kidneys. Good pulsations were restored. The patient is much improved. CASES

IN

GROUP

IV

There were three patients in this group. AI1 had evidence of biIatera1 depression of kidney function. One had a soIitary kidney. They were a11 in critica condition and a11 have done surprisingIy weI1. Certain data concerning them are summarized in TabIes IIIA and B. The patient in Case u was a fifty-four year old man with hypertension of ten years’ known duration when he was operated upon because of biIatera1 depression of renaI function associatied with rapid progression of hypertensive cardiovascuIar disease and a recent exacerbation of hypertension. He was first seen by us in April 1951, about ten years previousIy. At that time bIood pressure was 178/r 19 mm. Hg. His eyegrounds contained hemorrhages and exudates. Electrocardiogram was abnorma1 and his heart size was normaI. Kidney function was norma according to the phenoIsuIfonphthaIein output. Intravenous pyeIogram was norma in every respect. Blood urea nitrogen was normal. On sedation bIood pressure feI1 to 98/70 mm. Hg. BiIateraI SpIanchnicectomy was per118

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Hypertension

this admission,

this \~ulcl cncouragc the dcveIopment of collater-al circulation. The patient’s convalescence was uneventful. Renal biopsy showed Grade 3 arteriolar sclerosis, the same changes as were noted at the time of splanchnicectomy ten years earlier. At the time of discharge on the eIeventh postoperative day blood prcssurr was 224/142 mm. Hg. The phcnolsuIfonphthaIein output was 8 per cent in Iiftecn minutes and 27 per cent in two hours. Blood urea nitrogen was 32 mg. per cent. Fi\-e months Iater his blood pressure was 142/‘90 mm. Hg and blood urea nitrogen, 27 mg. per cent. He was taking rcserpine, 0.5 mg. twice a day, and DiuriI,O 250 mg., twice a day. One and a half years after operation blood pressure was 158/81 mm. Hp. BIood urea nitrogen continues to be mildIy eIevated and he responds to a modest quantity of antihypertensi\:e medication to which he prcviousIy was complctcly refractory. He is greatly improved symptomatically and is working fuIl time.

and at the timr

of admission

to the

hospital his blood pressure was 270,’ loo mm. llg. BIood urea nitrogen on admission was I $i mg. per cent and, therefore, an excretory urogram could not be performed. As is frequently the case in acute anuria, it was not possible to estimate the size of the kidneys on a KUB film of the abdomen; of course, because of the anuria a dividcti study of function was not performed, but normal renal pclves were demonstrated by retrograde pyelography; no urine was produced by the right krdney and only a few drops from the left. A retrograde renal angiogram was carried out which showed no filling of the right renal artcry and a block in the left renal artery 2 cm. from the aorta. It 1%as beIieved that the left kidney was probably the most saIvageabIe kidney and, accordingly, exploration was performed on this left kidney and left renal endarterectomy performed. At operation a recent thrombus was found in the main left renal artery and postoperatively severe arteriosclerosis of this artery was confirmed pathoIogicaIIy. Immcdrately foIlowing this first operation, blood pressure fell to a normal IcveI but graduaIIy returned to a IeveI of 210/110 mm. Hg four months postoperatively. It was believed at this time that his right kidney was probabIy a continuing stimulus for renal hypertension and, therefore, exploration of the right kidney was carried out and right nephrectomy performed. Two years following this operation his blood pressure is 120,430 mm. Hg and hc is not on any antihypertensive drugs.

The patient in Case 25 (Tables IIIA and B) was a sixty-three year old white woman who entered the hospital because of acute anuria of two days’ duration. Left nephrectomy had been performed eighteen years prior to this admission, probably because of a renal infarct resulting from an embolus, since this patient is known to have rheumatic heart disease with auricuIar fibrillation. At the time of her admission to the hospita1, bIood pressure was 175' 80 mm. Hg. An excretory urogram couId not be done because of her anuric state and a bIood urea nitrogen range of 81 to 147 mg. per cent. Because of her past history it was believed that another embolus was a distinct possibility and, accordingly, a Iumbar renaI angiogram was performed and revealed a constriction in the right renal artery with poor filling beyond this point. Because of this finding she underwent expIoration immediateIy. At operation the right renal artery was opened at the point of constriction and a clot removed from the arteria1 tree beyond the bifurcation of the main renaI artery as it entered the kidney; cndarterectomy was performed in the main rcna1 artery at the site of constriction. It was noted at operation that the upper pole of this solitary right kidney was infarcted and, accordingly, partial nephrectomy of the upper poIe was also pcrformcd. PostoperativeIy this patient’s blood urea nitrogen rose temporariIy but then returned to normal; her bIood pressure was I 20, 80 mm. IIg eight months postoperatively and has remained at this Ieve for three years.

SUMMARY

with the surgical management of forty-seven patients with hypertension of renal origin treated at the Massachusetts Memorial and the Peter Bent Brigham Hospitals are summarized. With four exceptions, the patients were operated upon during the past five years. The other patients have been folIowed up for eight to tweIve years. The cases were divided into four groups on the basis of difference in kidney size and dye excretion. Various diagnostic procedures are discussed with particular emphasis upon the information which can be gained from a carefu1 study of the fiIms obtained during intravenous urography. Particular attention has been paid to any difference in the size of the two kidneys as judged by over-a11 Iength and to function as measured by the excretion of the dye. This series of patients with hypertension of renaI origin was cuIIed from severa thousand hypertensive patients. There were forty-four cases of uniIatera1 renal disease, the uninvoIved kidneys having normal function. In three cases,

Experiences

The patient in Case 26 (Tables 1IIA and B) was a fifty-eight year old white man who entered the hospital because of acute anuria of four days’ duration. This patient was known to have a systolic blood pressure of 150 mm. Hg two years prior to

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there was biIatera1 depression of renaI function. One of these patients had a solitary kidney. In addition to certain features of the history and bIood pressure pattern (postura1 hypotension) which may aIert one to the possibiIity that hypertension of renaI origin may exist, the vaIue of the I’s1 Diodrast or HippurarP renogram is commented upon as a useful screening test. Of the definitive tests, differentia1 renal function studies by the method of Howard and modifications of it as we11 as arteriography by either the transIumbar or retrograde femora1 technics are discussed. Contrary to other series, these patients were not seIected primarily on the basis of arteriographic studies which outlined a vascular Iesion favorabIe to corrective surgery. Despite the fact that the renaI Iesion was of vascuIar origin in the great majority of patients, in onIy a few was direct surgery feasibIe. Nephrectomies were performed in nearIy a11 patients. OnIy five patients had primary parenchyma1 disease (advanced chronic pyeIonephritis). Attention is cahed to an interesting group of tweIve patients having what we have caIIed primary hypopIasia of the renaI artery and branches. The vesseIs were too smaI1 to be amenabIe to direct surgery and in most patients there was no organic pathoIogic condition. The right kidney was invoIved in the great majority of these particuIar patients. In attempting to predict the outcome of uniIateraI nephrectomy for hypertension, the probabIe importance of evidence of some degree of hypertrophy of the uninvoIved kidney is emphasized. One can be more conhdent of the outcome if the uninvolved kidney is 13 cm. in Iength or more. AIso, it was noted that as the difference in the size of the two kidneys increases, the uninvoIved kidney enIarges further in patients with a good result; however, the eventua1 difference in size resuIts more from a decrease in the Iength of the invoIved kidney than from an increase in Iength of the uninvolved kidney. Also, it wouId appear that when the Iength of the invoIved kidney is IO cm. or Iess, aImost certainly if Iess than IO cm., the

and Harrison

chances of salvaging the involved kidney by direct surgery are remote because of secondary if not primary hypoplasia of the renaI bIood supply, totaIIy aside from the frequent occurrence of both main artery and branch lesions. Attention is caIIed to the fact that the Iarger kidney may occasionaIIy be the cuIprit. We have the impression that nephrectomy wiI1 be necessary more often than it is possibIe to carry out corrective vascuIar surgery in patients with renaI hypertension seIected from a representative cross section of a11 patients with hypertension. We, however, reaIize that patients whose hypertension is amenabIe to direct vascuIar surgery can be selected from the hypertensive popuIation on the basis of arteriography in which a high percentage of earIy favorabIe responses wiI1 be obtained, especiaIIy if the arteriographic evidence is supported by cIearcut differentia1 renaI function studies and adequate pressure gradients noted at expIoration. Various case reports are incIuded to emphasize certain points as we11 as to caI1 attention to some of our mistakes so that they may be avoided by others. The over-al1 resuIts in this group of surgically treated patients were very satisfactory. The operative mortaIity was 2 per cent. The subsequent mortaIity was 4 per cent. One of these patients had an exceIIent resuIt and a normal IeveI of bIood pressure but died three and a haIf years after operation of a cerebra1 hemorrhage. The other was improved but died two and a half years Iater of pneumonia. Twenty-nine patients (62 per cent) had exceIIent resuIts, thirteen (28 per cent) were improved and there were two (4 per cent) failures. Thus, satisfactory resuIts, as judged by blood pressure IeveIs and genera1 cardiovascuIar status, were obtained in 90 per cent of the patients. REFERENCE I. HOWARD, J. E., BERTHRONG, M., SLOAN, R. D. and YENDT, E. R. Relief of malignant hypertension by

nephrectomy in 4 patients with unilateral renaI vascuIar disease. Tr. A. Am. Physicians, 66: 164, ‘953.

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