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Surgically Correctable Hypertension of Renal Origin in Childhood
880
DISEASES OF BLOOD VESSELS, HYPERTENSION AND RENOVASCULAR SURGERY
DISEASES OF BLOOD VESSELS, HYPERTENSION AND RENOVASCULAR SURGERY Clinical Use of Thrombolytic Agents in Venous Thromboembolism G. V. R. K. SHARMA, D. E. Tow, K. M. A. F. PARISI AND G. CELLA, Medical, Nuclear Medicine and Research Services, West Roxbury Veterans Administration Medical Center and Departments of Medicine and Nuclear Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
A. A.
SASAHARA,
McINTYRE,
Arch. Intern. Med., 142: 684-688 (Apr.) 1982 In April 1980 a National Institutes of Health Consensus Development Conference was held on thrombolytic therapy in thrombosis and a strong summary statement was issued in favor of the use of thrombolytic agents in venous thromboembolisµi. The statement emphasized that through proper use of the thrombolytic agents in conjunction with anticoagulants the following objectives of ideal management could be achieved: 1) rapid lysis of thrombi and emboli to restore the circulation to normal, 2) rapid normalization of the hemodynamic disturbances to pulmonary embolism and reduction of morbidity, 3) prevention of venous valvular damage and subsequent venous hypertension in the lower extremities, and 4) prevention of permanent damage to the pulmonary vascular bed and reduction of the likelihood of persistent pulmonary hypertension. These objectives could be achieved provided 1) the diagnosis was adequately established, 2) the severity of the clinical problem exceeded the risk of bleeding associated with a major contraindication, 3) proper care was taken in the treatment of the patient and in the avoidance of unnecessary invasive procedures, and 4) there was a clear understanding of the details of treatment, including monitoring, management of bleeding complications and the control of subsequent anticoagulation. The consensus statement further emphasized that when used in tandem with anticoagulation, thrombolytic therapy, as currently practiced, represents an important advance in the management of proximal deep vein thrombosis and the more severe forms of pulmonary embolism. With further developments aimed at improving its efficacy and reducing the bleeding risk, this form of therapy could become the initial treatment of all forms of acute deep vein thrombosis and pulmonary embolism. The use of thrombolytic agents in venous thromboembolism has been shown to be highly effective. Patients treated with lytic agents show more rapid clot resolution and lung re-perfusion, and more rapid and greater reversal of the abnormal hemodynamic responses to pulmonary embolism than patients receiving heparin. Moreover, lytic therapy removes thromboemboli more completely from the pulmonary microcirculation, whereas residual thromboemboli tend to accumulate with heparin therapy. In addition, lytic therapy tends to preserve the venous valves, whereas distortion and destruction occur with heparin therapy. Hence, lytic therapy confers a number of short-term and long-term benefits not observed with heparin therapy. G.P.M. 3 figures, 1 table, 9 references
Surgically Correctable Hypertension of Renal Origin in Childhood
w.
s. H. KIM, J. T. HERRIN AND J. D. Division of Pediatric Surgery and Children's
H. HENDREN,
CRAWFORD,
Service, Massachusetts General Hospital, and Department of Surgery and Pediatrics, Harvard Medical School, Boston, Massachusetts Amer. J. Surg., 143: 432-442 (Apr.) 1982 In 1937 Butler reported successful treatment of hypertension by removing the kidney with atrophic pyelonephritis. In 1938 Leadbetter and Burkland reported the first case ofrenovascular hypertension cured by removing an ectopic kidney from a 5year-old boy. The disease proved to be fibromuscular dysplasia of the renal artery. For the next 35 years most of the reported cases of renovascular hypertension in children were treated by nephrectomy. In 1954 the first successful vascular reconstruction in an adult was reported. In the last decade greater emphasis has been placed on repair of renal artery stenosis whenever feasible rather than the removal of the kidney. The clinical picture of renovascular hypertension has been well described. In all young patients with hypertension excretory urography should be performed to eliminate the possibility of a malformed kidney. A congenitally small kidney or one scarred from vesicoureteral reflux and infection can cause hypertension. If a small kidney is found voiding cystourethrography also should be performed to determine whether the problem is reflux nephropathy, which is a well recognized cause of renin-dependent hypertension in kidneys with segmental scars, or chronic pyelonephritis believed to be ischemia of the relatively normal renal cortex next to areas of scarring, in which there are tortuous arterioles with intimal thickening. Peripheral renin levels should be obtained, along with selective renal vein renin determinations when aortography is performed. The ratio of renal vein renin from the affected kidney (Ra) is compared to the contralateral normal or less affected kidney (Re). An Ra/Re ratio >1.5 to 2.0 indicates asymmetric release of renin. The ratio of the renin level in the inferior vena cava below the renal veins (Rive) and the contralateral kidney (Re/Rive) is used to determine if suppression of renin from the better kidney is possible, that is that vessel damage from hypertension has not occurred. A good response to surgery would be expected if asymmetric renin release is present. Review of the available reports on pediatric renovascular hypertension discloses that most cases reported before 1970 were treated by nephrectomy. During the last decade there has been a much greater emphasis on the feasibility of vascular repair. A variety of surgical techniques can be considered in repair of a narrow vessel. Since 1960, 22 children have been treated for surgically correctable hypertension of renal origin. The series included 2 children with tumors, 2 with hydronephrosis from ureteropelvic junction obstruction, 9 in whom 1 kidney was atrophic and 9 with renal artery narrowing from fibromuscular dysplasia (with bilateral involvement in 2). Hypertension was cured in the patients with tumors and ureteropelvic junction obstruction, and also in 4 of the 9 patients with an atrophic kidney and in 5 of the 9 with a narrow renal artery. In those patients who were not cured hypertension was more easily controlled by medication. One patient died of brain hypoxia during the operation. About 10 per cent of the children investigated for hypertension at the authors' hospital proved to have a surgically correctable cause of renal origin. G.P.M. 9 figures, 36 references
Editorial comment. The incidence of childhood hypertension, as shown by the appreciation of only 227 children with hypertension in a large clinical setting such as that of the authors, is low. Those patients surgically correctable represent
881 a mere fraction of the child 'fhis report is most t,,,,.,,_,trna because most urologists see a limited number of surgically correctable hypertensive patients in a lifetime. The authors indicate that renal vascular disease was not the most common cause of surgically correctable hypertension in children. Correct preoperative studies are essential to proper therapy. A.T.E.
Percutaneous Transluminal Renal Angioplasty. A Potentially Effective Treatment for Preservation of Renal Function
N. E. MADIAS, 0. J. KwoN AND V. G. MILLAN, Renal and Cardiovascular Radiology Services, Tufts-New England Medical Center, and Departments of Medicine and Radiology, Tufts University School of Medicine, Boston, Massachusetts Arch. Intern. Med., 142: 693-697 (Apr.) 1982 Percutaneous transluminal renal angioplasty has emerged recently as a potential alternative to a renovascular operation in the treatment ofrenovascular hypertension. Currently, available experience with the application of this novel approach has been quite encouraging, albeit uncontrolled, limited and shorttermed. Nevertheless, it has provided a reasonable basis for the consideration of percutaneous transluminal renal angioplasty as a potentially effective modality in the management of selected cases of renovascular hypertension. Most recently, short-term data were reported on 5 patients in whom percutaneous transluminal renal angioplasty was used primarily for the preservation of renal function. These patients had marked impairment in renal function and hypertension owing to severe atherosclerotic renal artery stenosis in a solitary functioning kidney. In 3 of these patients the procedure resulted in improvement in renal function and hypertension. Schwarten also has reported on the application of percutaneous transluminal renal angioplasty for the preservation of renal function. However, the limited data provided in his report do not allow evaluation of the results obtained. Percutaneous transluminal renal angioplasty was performed on 12 patients with marked renal functional impairment, severe hypertension and critical renovascular stenoses in a solitary functioning kidney (10 patients) or bilaterally (2 patients). The procedure led to at least partial dilation in 11 of the 13 stenoses acted on and stabilization or modest improvement in renal function in 7 of the 11 patients in whom some technical success had been achieved. """''"''"'" the severity of the hypertension appeared to be favorably affected following percutaneous transluminal renal angioplasty. Complications that were encountered included 3 episodes of nonoliguric acute renal failure, a thrombotic occlusion of a renal artery, a tear of the balloon segment of the catheter requiring femoral arteriotomy and an episode of gastrointestinal tract bleeding. Percutaneous transluminal renal angioplasty may be an effective modality in the treatment of patients with severe renovascular stenosis, renal functional impairment and hypertension. G.P.M. 3 figures, 1 table, 27 references.
Glome:rula:r and Tubular Function in Non-Oliguric Acute Renal Failure
B. D.
M. HILBERMAN, R. J. SPENCER AND R. L. Division of Nephrology, Departments of Medicine and Anesthesia, Stanford University School of Medicine, Stanford, California MYERS,
JAMISON,
Amer. J. Med., 72: 642-649
1982
The purpose of this study was to evaluate some aspects of renal tubular and glomernlar function, and to relate them to the clinical course of 30 patients suffering nonoliguric renal failure after an open heart operation. All patients received 25 to 50 gm. mannitol during the operation. They were evaluated when they were stable hemodynamically, and during a period when serum creatinine and blood urea nitrogen were increasing. Renal clearances of sodium, potassium, creatinine, para-aminohippurate, dextran of graded sizes and inulin were determined by the standard methods. Fractional clearances of various test solutes relative to that of inulin were calculated by dividing the clearance of the respective solute by the respective inulin clearance. In 16 patients fractional clearance of dextran relative to that of inulin was more than unity, indicating backflow of inulin through the necrotic tubular epithelium. This group of patients was classified as having acute renal failure. Of these 16 patients 14 required dialysis. In the remaining 14 patients the fractional clearance of dextran relative to that of inulin was normal, indicating that there was no significant backflow of inulin into the interstitium. This group of patients was classified as having prerenal azotemia. None of these patients required dialysis. Determination of inulin clearance in acute renal failure and in prerenal failure revealed that the glomernlar filtration rate was lower in the former. However, when correction was made for backflow of inulin in acute renal failure no difference in the glomerular filtration rate of these 2 groups was noted. Vvhen compared to normal individuals glomerular filtration rate was reduced significantly in acute renal and prerenal failure. Determination of fractional clearances of para-aminohippurate and potassium in acute renal failure revealed that proximal and distal tubules retained the ability to secrete these substances. However, the tubules were found to have lost their ability to reabsorb sodium and water as evidenced by the determination of fractional clearance of sodium. This resulted in the excretion of large amounts of urine. The authors conclude that the patients who exhibited the evidence of tubular backflow of inulin (classified as acute renal failure) had a more dramatic clinical course and the majority of them required dialysis, compared to those who did not show tubular backflow (classified as prerenal failure). The latter g-roup of patients responded to more conservative therapy.
N.S.D. 2 figures, 3 tables, 35 references.
TRANSPLANTATION Evaluation of Recurrent Glomernloneph:ritis in Kidney Allografts
B. P. CROKER, JR., H. F. SEIGLER AND C. C. Division of Nephrology, Departments of Medicine and Pathology, Duke University Medical Center, Durham, North Carolina
M. MoRZYCKA, TISHER,
Amer. J. Med., 72: 588-598 (Apr.) 1982 This is a retrospective study on the incidence and pathological findings of recurrent glomerulonephritis in transplanted kidneys. A total of 320 patients received 350 renal homografts during a 12-year period. The recipients ranged in age from 6 to 56 years, 231 of whom were male and 89 were female patients. The kidneys were obtained from 167 living related donors and 183 cadavers. The native kidney tissue was available for patho-
DISEASES OF BLOOD VESSELS, HYPERTENSION AND RENOVASCULAR SURGERY
DISEASES OF BLOOD VESSELS, HYPERTENSION AND RENOVASCULAR SURGERY Clinical Use of Thrombolytic Agents in Venous Thromboembolism G. V. R. K. SHARMA, D. E. Tow, K. M. A. F. PARISI AND G. CELLA, Medical, Nuclear Medicine and Research Services, West Roxbury Veterans Administration Medical Center and Departments of Medicine and Nuclear Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
A. A.
SASAHARA,
McINTYRE,
Arch. Intern. Med., 142: 684-688 (Apr.) 1982 In April 1980 a National Institutes of Health Consensus Development Conference was held on thrombolytic therapy in thrombosis and a strong summary statement was issued in favor of the use of thrombolytic agents in venous thromboembolisµi. The statement emphasized that through proper use of the thrombolytic agents in conjunction with anticoagulants the following objectives of ideal management could be achieved: 1) rapid lysis of thrombi and emboli to restore the circulation to normal, 2) rapid normalization of the hemodynamic disturbances to pulmonary embolism and reduction of morbidity, 3) prevention of venous valvular damage and subsequent venous hypertension in the lower extremities, and 4) prevention of permanent damage to the pulmonary vascular bed and reduction of the likelihood of persistent pulmonary hypertension. These objectives could be achieved provided 1) the diagnosis was adequately established, 2) the severity of the clinical problem exceeded the risk of bleeding associated with a major contraindication, 3) proper care was taken in the treatment of the patient and in the avoidance of unnecessary invasive procedures, and 4) there was a clear understanding of the details of treatment, including monitoring, management of bleeding complications and the control of subsequent anticoagulation. The consensus statement further emphasized that when used in tandem with anticoagulation, thrombolytic therapy, as currently practiced, represents an important advance in the management of proximal deep vein thrombosis and the more severe forms of pulmonary embolism. With further developments aimed at improving its efficacy and reducing the bleeding risk, this form of therapy could become the initial treatment of all forms of acute deep vein thrombosis and pulmonary embolism. The use of thrombolytic agents in venous thromboembolism has been shown to be highly effective. Patients treated with lytic agents show more rapid clot resolution and lung re-perfusion, and more rapid and greater reversal of the abnormal hemodynamic responses to pulmonary embolism than patients receiving heparin. Moreover, lytic therapy removes thromboemboli more completely from the pulmonary microcirculation, whereas residual thromboemboli tend to accumulate with heparin therapy. In addition, lytic therapy tends to preserve the venous valves, whereas distortion and destruction occur with heparin therapy. Hence, lytic therapy confers a number of short-term and long-term benefits not observed with heparin therapy. G.P.M. 3 figures, 1 table, 9 references
Surgically Correctable Hypertension of Renal Origin in Childhood
w.
s. H. KIM, J. T. HERRIN AND J. D. Division of Pediatric Surgery and Children's
H. HENDREN,
CRAWFORD,
Service, Massachusetts General Hospital, and Department of Surgery and Pediatrics, Harvard Medical School, Boston, Massachusetts Amer. J. Surg., 143: 432-442 (Apr.) 1982 In 1937 Butler reported successful treatment of hypertension by removing the kidney with atrophic pyelonephritis. In 1938 Leadbetter and Burkland reported the first case ofrenovascular hypertension cured by removing an ectopic kidney from a 5year-old boy. The disease proved to be fibromuscular dysplasia of the renal artery. For the next 35 years most of the reported cases of renovascular hypertension in children were treated by nephrectomy. In 1954 the first successful vascular reconstruction in an adult was reported. In the last decade greater emphasis has been placed on repair of renal artery stenosis whenever feasible rather than the removal of the kidney. The clinical picture of renovascular hypertension has been well described. In all young patients with hypertension excretory urography should be performed to eliminate the possibility of a malformed kidney. A congenitally small kidney or one scarred from vesicoureteral reflux and infection can cause hypertension. If a small kidney is found voiding cystourethrography also should be performed to determine whether the problem is reflux nephropathy, which is a well recognized cause of renin-dependent hypertension in kidneys with segmental scars, or chronic pyelonephritis believed to be ischemia of the relatively normal renal cortex next to areas of scarring, in which there are tortuous arterioles with intimal thickening. Peripheral renin levels should be obtained, along with selective renal vein renin determinations when aortography is performed. The ratio of renal vein renin from the affected kidney (Ra) is compared to the contralateral normal or less affected kidney (Re). An Ra/Re ratio >1.5 to 2.0 indicates asymmetric release of renin. The ratio of the renin level in the inferior vena cava below the renal veins (Rive) and the contralateral kidney (Re/Rive) is used to determine if suppression of renin from the better kidney is possible, that is that vessel damage from hypertension has not occurred. A good response to surgery would be expected if asymmetric renin release is present. Review of the available reports on pediatric renovascular hypertension discloses that most cases reported before 1970 were treated by nephrectomy. During the last decade there has been a much greater emphasis on the feasibility of vascular repair. A variety of surgical techniques can be considered in repair of a narrow vessel. Since 1960, 22 children have been treated for surgically correctable hypertension of renal origin. The series included 2 children with tumors, 2 with hydronephrosis from ureteropelvic junction obstruction, 9 in whom 1 kidney was atrophic and 9 with renal artery narrowing from fibromuscular dysplasia (with bilateral involvement in 2). Hypertension was cured in the patients with tumors and ureteropelvic junction obstruction, and also in 4 of the 9 patients with an atrophic kidney and in 5 of the 9 with a narrow renal artery. In those patients who were not cured hypertension was more easily controlled by medication. One patient died of brain hypoxia during the operation. About 10 per cent of the children investigated for hypertension at the authors' hospital proved to have a surgically correctable cause of renal origin. G.P.M. 9 figures, 36 references
Editorial comment. The incidence of childhood hypertension, as shown by the appreciation of only 227 children with hypertension in a large clinical setting such as that of the authors, is low. Those patients surgically correctable represent
881 a mere fraction of the child 'fhis report is most t,,,,.,,_,trna because most urologists see a limited number of surgically correctable hypertensive patients in a lifetime. The authors indicate that renal vascular disease was not the most common cause of surgically correctable hypertension in children. Correct preoperative studies are essential to proper therapy. A.T.E.
Percutaneous Transluminal Renal Angioplasty. A Potentially Effective Treatment for Preservation of Renal Function
N. E. MADIAS, 0. J. KwoN AND V. G. MILLAN, Renal and Cardiovascular Radiology Services, Tufts-New England Medical Center, and Departments of Medicine and Radiology, Tufts University School of Medicine, Boston, Massachusetts Arch. Intern. Med., 142: 693-697 (Apr.) 1982 Percutaneous transluminal renal angioplasty has emerged recently as a potential alternative to a renovascular operation in the treatment ofrenovascular hypertension. Currently, available experience with the application of this novel approach has been quite encouraging, albeit uncontrolled, limited and shorttermed. Nevertheless, it has provided a reasonable basis for the consideration of percutaneous transluminal renal angioplasty as a potentially effective modality in the management of selected cases of renovascular hypertension. Most recently, short-term data were reported on 5 patients in whom percutaneous transluminal renal angioplasty was used primarily for the preservation of renal function. These patients had marked impairment in renal function and hypertension owing to severe atherosclerotic renal artery stenosis in a solitary functioning kidney. In 3 of these patients the procedure resulted in improvement in renal function and hypertension. Schwarten also has reported on the application of percutaneous transluminal renal angioplasty for the preservation of renal function. However, the limited data provided in his report do not allow evaluation of the results obtained. Percutaneous transluminal renal angioplasty was performed on 12 patients with marked renal functional impairment, severe hypertension and critical renovascular stenoses in a solitary functioning kidney (10 patients) or bilaterally (2 patients). The procedure led to at least partial dilation in 11 of the 13 stenoses acted on and stabilization or modest improvement in renal function in 7 of the 11 patients in whom some technical success had been achieved. """''"''"'" the severity of the hypertension appeared to be favorably affected following percutaneous transluminal renal angioplasty. Complications that were encountered included 3 episodes of nonoliguric acute renal failure, a thrombotic occlusion of a renal artery, a tear of the balloon segment of the catheter requiring femoral arteriotomy and an episode of gastrointestinal tract bleeding. Percutaneous transluminal renal angioplasty may be an effective modality in the treatment of patients with severe renovascular stenosis, renal functional impairment and hypertension. G.P.M. 3 figures, 1 table, 27 references.
Glome:rula:r and Tubular Function in Non-Oliguric Acute Renal Failure
B. D.
M. HILBERMAN, R. J. SPENCER AND R. L. Division of Nephrology, Departments of Medicine and Anesthesia, Stanford University School of Medicine, Stanford, California MYERS,
JAMISON,
Amer. J. Med., 72: 642-649
1982
The purpose of this study was to evaluate some aspects of renal tubular and glomernlar function, and to relate them to the clinical course of 30 patients suffering nonoliguric renal failure after an open heart operation. All patients received 25 to 50 gm. mannitol during the operation. They were evaluated when they were stable hemodynamically, and during a period when serum creatinine and blood urea nitrogen were increasing. Renal clearances of sodium, potassium, creatinine, para-aminohippurate, dextran of graded sizes and inulin were determined by the standard methods. Fractional clearances of various test solutes relative to that of inulin were calculated by dividing the clearance of the respective solute by the respective inulin clearance. In 16 patients fractional clearance of dextran relative to that of inulin was more than unity, indicating backflow of inulin through the necrotic tubular epithelium. This group of patients was classified as having acute renal failure. Of these 16 patients 14 required dialysis. In the remaining 14 patients the fractional clearance of dextran relative to that of inulin was normal, indicating that there was no significant backflow of inulin into the interstitium. This group of patients was classified as having prerenal azotemia. None of these patients required dialysis. Determination of inulin clearance in acute renal failure and in prerenal failure revealed that the glomernlar filtration rate was lower in the former. However, when correction was made for backflow of inulin in acute renal failure no difference in the glomerular filtration rate of these 2 groups was noted. Vvhen compared to normal individuals glomerular filtration rate was reduced significantly in acute renal and prerenal failure. Determination of fractional clearances of para-aminohippurate and potassium in acute renal failure revealed that proximal and distal tubules retained the ability to secrete these substances. However, the tubules were found to have lost their ability to reabsorb sodium and water as evidenced by the determination of fractional clearance of sodium. This resulted in the excretion of large amounts of urine. The authors conclude that the patients who exhibited the evidence of tubular backflow of inulin (classified as acute renal failure) had a more dramatic clinical course and the majority of them required dialysis, compared to those who did not show tubular backflow (classified as prerenal failure). The latter g-roup of patients responded to more conservative therapy.
N.S.D. 2 figures, 3 tables, 35 references.
TRANSPLANTATION Evaluation of Recurrent Glomernloneph:ritis in Kidney Allografts
B. P. CROKER, JR., H. F. SEIGLER AND C. C. Division of Nephrology, Departments of Medicine and Pathology, Duke University Medical Center, Durham, North Carolina
M. MoRZYCKA, TISHER,
Amer. J. Med., 72: 588-598 (Apr.) 1982 This is a retrospective study on the incidence and pathological findings of recurrent glomerulonephritis in transplanted kidneys. A total of 320 patients received 350 renal homografts during a 12-year period. The recipients ranged in age from 6 to 56 years, 231 of whom were male and 89 were female patients. The kidneys were obtained from 167 living related donors and 183 cadavers. The native kidney tissue was available for patho-