U. Kuhlmann

Long-term experience in percutaneous transluminal dilatation of renal artery stenosis

Percutaneous transluminal dilatation was attempted in 65 patients with renovascular hypertension. In five cases (8 percent), percutaneous transluminal dilatation could not be performed for technical reasons. In the remaining 60 patients (35 with atherosclerotic stenosis and 25 with fibromuscular dysplasia), both mean systolic and diastolic pressure fell immediately after percutaneous transluminal dilatation and remained significantly lower for a period of up to five years. Cure rates after a mean control period of 21.6 months were higher in patients with fibromuscular dysplasia (50 percent) than in those with atherosclerotic stenosis (29 percent). Improvement of blood pressure was observed in 32 percent of patients with fibromuscular dysplasia and in 48 percent of patients with atherosclerotic stenosis. Follow-up angiography in 33 cases showed occlusion of the dilated artery in two patients and recurrence of slight renal artery stenosis in nine patients. Successful redilatation could be performed in five of these cases. Furthermore, renal vein renin determinations were only of limited diagnostic or prognostic value. These results document the good long-term effect of percutaneous transluminal dilatation in patients with renal artery stenosis. Percutaneous transluminal dilatation should, therefore, be the favored procedure in patients with renovascular hypertension.

Cure and Improvement of Renovascular Hypertension after Percutaneous Transluminal Angioplasty of Renal Artery Stenosis

In the present study we report our long-term experience in 82 patients with renovascular hypertension (48 with atherosclerotic stenosis, 34 with fibromuscular dysplasia) who were followed up for a mean observation period of 23.6 months after percutaneous transluminal angioplasty (PTA) of renal artery stenosis. Our results show a highly significant decrease in mean systolic and diastolic blood pressure. Cure rates were slightly higher in patients with fibromuscular dysplasia (41% cured, 47% improved) than in those with atherosclerosis (23% cured, 54% improved). Kidney function significantly improved in patients with cure, remained stable in those with improvement and worsened in cases classified as unimproved. These results document the good long-term effect of PTA on blood pressure and kidney function in patients with renal artery stenosis.

Surgery, Transluminal Dilatation and Medical Therapy in the Management of Renovascular Hypertension

In the present retrospective study, the effect of various therapeutic procedures (surgery, percutaneous transluminal dilatation and antihypertensive drugs) was analyzed in 202 patients with renovascular hypertension. The results show that each of the three methods effectively lowers blood pressure. However, marked differences were observed in pretreatment clinical and laboratory data among the three groups. These differences were most probably caused by different selection criteria before submitting the patient to a given therapeutic regime. Our findings also demonstrate that on the basis of the present analysis a direct comparison between surgery, dilatation and medical therapy is not possible.

Percutaneous transluminal dilatation: a new treatment of renovascular hypertension?

ZusammenfassungBei einem 61jährigen Patienten mit renovasculärer Hypertonie bei linksseitiger arteriosklerotischer Nierenarterienstenose wurde eine perkutane transluminale Dilatation der Stenose vorgenommen. Die biochemische und hämodynamische Aktivität der Nierenarterienstenose wurde durch Messung der Plasmareninaktivität im Nierenvenenblut, Bestimmung des renalen Plasmaflusses und der prä- und poststenotischen Blutdruckwerte in der Nierenarterie belegt.Kurz nach der Dilatation der Stenose normalisierte sich der Blutdruck, und es kam zu einem Anstieg des renalen Plasmaflusses. Weitere Untersuchungen werden zeigen, ob die beschriebene Methode eine Alternative zur operativen Korrektur der Nierenarterienstenose bietet.SummaryPercutaneous transluminal dilatation of a left sided renal artery stenosis was performed in a 61 year old patient with hypertension. Biochemical and hemodynamic activity of the renal artery stenosis was demonstrated by measurement of renal venous renin-activity and determination of renal plasma flow and of pre- and poststenotic blood pressure values.Shortly after the dilatation procedure hypertension disappeared and renal plasma flow increased.The described procedure might be an alternative method to renal vascular surgery.

Unilateral Parenchymatous Kidney Disease and Hypertension: Results of Nephrectomy and Medical Treatment

In the present study 43 patients with unilateral parenchymatous kidney disease and hypertension were investigated. 20 patients were nephrectomized, 23 treated with antihypertensive drugs. Both therapeutic approaches showed an excellent and sustained blood pressure-(BP)-lowering effect. BP fell from 185 +/- 27/116 +/- 13 to 138 +/- 20/86 +/- 10 mm Hg in the operated and from 194 +/- 32/116 +/- 13 to 149 +/- 22/95 +/- 12 mm Hg in the medically treated patients after 2 and 6 weeks, respectively (p less than 0.001). BP was 142 +/- 16/89 +/- 11 and 136 +/- 16/90 +/- 10 mm Hg at the long-term follow-up in the 2 subgroups. In the operated group 70% (n = 14) were cured, 20% (n = 4) were improved and 10% (n = 2) unimproved. In the medically treated group 65% (n = 15) were normotensive, 26% (n = 6) improved and 9% (n = 2) treatment resistant. No significant correlation between postoperative BP reduction and lateralization of renin secretion (PRA-ratio greater than or equal to 1.5) was found. Although cured patients showed a higher mean PRA-ratio, 4 patients with a PRA-ratio less than 1.5 were cured (n = 2) or improved (n = 2) postoperatively. Our results document an excellent and sustained antihypertensive effect of both nephrectomy and medical treatment in patients with unilateral parenchymatous kidney disease and hypertension. They further limit the predictive value of renal venous renin determination in the preoperative workup.

[Extrarenal fibromuscular hyperplasia with renovascular hypertension (author's transl)].

SummaryIn the present study 10 patients with renovascular hypertension due to fibromuscular hyperplasia and fibromuscular lesions of extrarenal arteries were investigated.The 10 patients were predominantly female (90%), showed a mean age of 31.4±12.0 years and a mean duration of hypertension of 3.2±4.0 years.Four of the 10 patients (40%) showed unilateral and six (60%) bilateral stenosis or occlusions of the renal arteries. In two (20%) cases a combination of renal artery stenosis and coarctation of the abdominal aorta was observed. Other extrarenal arteries were affected as follows: mesenteric superior artery (50%), subclavian artery and/or arteria anonyma (40%), carotid arteries and/ or their branches (30%), vertebral arteries (10%), and mesenteric inferior artery (10%).In eight of the 10 patients the most prominent clinical symptom was hypertension. Clinical symptoms from extrarenal artery stenoses or occlusions were mild. Two patients with fibromuscular lesions of two and three intestinal arteries, respectively, suffered from angina abdominalis. In two cases with stenoses of the iliacal arteries intermittent claudicatio was observed, whereas involvement of the subclavian artery was associated with only mild symptoms. One patient with occlusions of both internal carotid arteries had two episodes of cerebrovascular ischemia.Plasma renin activity was determined in both renal veins in seven of the 10 patients (70%). Four of the seven patients (57%) showed a PRA-ratio of ≧1.5 either under basal conditions or 15 and/or 30 min after i.v. stimulation with 40 mg furosemide.Only one of the five patients with revascularization operations was cured postoperatively. In one patient only the intestinal arteries were operated. Three of five cases treated with various antihypertensive drugs were normotensive.Our results show that in patients with renovascular hypertension due to fibromuscular hyperplasia extrarenal arteries may be frequently affected. The most frequent site of extrarenal lesions was the mesenteric superior artery. In two of the 10 patients renovascular hypertension was combined with a coarctation of the abdominal aorta.In this study the effect of reconstructive renovascular surgery was insufficient. Thus, these cases should first be treated with antihypertensive drugs. The diagnostic validity of renal venous renin activity was limited because of the high percentage of bilateral renovascular lesions.ZusammenfassungIn der vorliegenden Studie wurden 10 Fälle mit fibromuskulär bedingter renovaskulärer Hypertonie und gleichzeitigem Befall extrarenaler Arterien untersucht.Das Patientenkollektiv zeigte eine deutliche Prävalenz des weiblichen Geschlechts (90%), das mittlere Alter betrug 31,4±12,0 Jahre und die Hypertoniedauer 3,2±4,0 Jahre.4 der 10 Patienten wiesen Stenosen einer und 6 Stenosen bzw. Verschlüsse beider Nierenarterien auf. 2 (20%) Patientinnen zeigten neben fibromuskulären Umbauprozessen der Nierenarterien eine abdonale Coarctatio aortae. Andere Körperarterien waren mit abnehmender Häufigkeit wie folgt befallen: Arteria mesenterica superior (50%), Arteria subclavia und/oder Truncus brachiocephalicus (40%), Arteriae carotides und/oder deren Äste (30%), Truncus coeliacus (30%), Arterien der Beckenstrombahn (30%), Arteriae vertebrales (10%) und Arteria mesenterica inferior (10%).Im Vordergrund der klinischen Symptomatik stand bei 8 der 10 Patienten die Hypertonie. Beschwerden von seiten extrarenaler Gefäßveränderungen waren in diesen Fällen bei Diagnosestellung gering. In 2 Fällen mit Befall von 2 bzw. aller 3 Intestinalgefäße bestand eine Angina abdominalis. 2 Patientinnen mit Stenosen der Beckengefäße zeigten eine Claudicatio intermittens, während Stenosen bzw. Verschlüsse im Subclaviabereich nur bei starker Belastung zu Claudicationsbeschwerden führten und deshalb über einen längeren Zeitpunkt unerkannt blieben. Eine Patientin mit Verschlüssen der Arteriae carotides internae hatte zweimal einen cerebralen Insult durchgemacht.Eine seitengetrennte Bestimmung der Plasma-Renin-Aktivität im Nierenvenenblut wurde bei 7 der 10 Patienten durchgeführt. Dabei zeigten 4 dieser 7 Fälle entweder unter Ausgangsbedingungen oder 15 bzw. 30 min nach intravenöser Stimulation mit 40 mg Furosemid einen signifikanten Seitenunterschied (≧ 1,5).Bei 5 der 10 Patienten wurde eine rekonstruktive Gefäßoperation an den Nierenarterien und bei einem Patienten ein solcher nur an den Intestinalarterien vorgenommen; dabei zeigte nur einer der 5 an den Nierenarterien operierten Fälle eine Heilung. Bei 3 der 5 medikamentös behandelten Patienten ließ sich eine Blutdrucknormalisierung durch Antihypertensiva erzielen.Unsere Ergebnisse zeigen, daß bei Patienten mit fibromuskulär bedingter Nierenarterienstenose verschiedenste Körperarterien mitbeteiligt sein können, am häufigsten jedoch die Arteria mesenterica superior. Bei 2 der 10 Patienten fand sich neben der renovaskulären Hypertonie eine Coarctatio aortae. Wegen des schlechten Operationserfolges sollte zunächst der Versuch einer medikamentösen Blutdruckeinstellung unternommen werden. Wegen des hohen Anteils doppelseitiger Nierenarterienstenosen hat die seitengetrennte Bestimmung der Plasma-Renin-Aktivität im Nierenvenenblut nur eine beschränkte Aussagekraft.

Control of plasma aldosterone in diabetic patients with hyporeninemic hypoaldosteronism

ZusammenfassungBei drei Patienten mit Diabetes mellitus und hyporeninämischem Hypoaldosteronismus wurden Veränderungen der Plasmareninaktivität, des Plasmaaldosteron- und Plasmacortisolspiegels unter folgenden Bedingungen geprüft: Orthostase und intravenöse Furosemidapplikation, Infusion von synthetischem β1–24 ACTH an zwei aufeinanderfolgenden Tagen, Tag-Nacht-Rhythmus der basalen Hormonplasmaspiegel.Alle Patienten zeigten eine nicht meßbare und durch Orthostase und Furosemid nicht stimulierbare Reninaktivität. Gleichzeitig wurden subnormale Aldosteronplasmakonzentrationen gemessen. Unter ACTH-Infusion zeigte nur ein Patient einen deutlichen Anstieg des Plasmaaldosterons, während das Plasmacortisol in allen drei Fällen normal stimulierbar war.Die statistische Analyse der Tag-Nacht-Schwankungen von Plasmaaldosteron und Plasmacortisol zeigte in jedem der Fälle eine enge und statistisch signifikante Beziehung zwischen beiden Hormonen (p<0,05–<0,001). Es ist somit anzunehmen, daß Schwankungen des Plasmaaldosterons durch Veränderungen der hypophysären ACTH-Ausschüttung verursacht wurden. Jedoch war im Vergleich zu Normalpersonen die Rhythmik des basalen Plasmaaldosterons auf einem tieferen Niveau eingestellt. Unsere Ergebnisse lassen den Schluß zu, daß bei diesen Patienten nicht eine verminderte Sensitivität der Nebennierenrinde auf ACTH für die beobachteten subnormalen Aldosteronspiegel verantwortlich ist.Ursache für den Hypoaldosteronismus scheint somit der Mangel an zirkulierendem Angiotensin II zu sein. Der genaue Mechanismus der nicht meßbaren Reninaktivität bei diesem Patienten bleibt unbekannt.SummaryIn three patients with diabetes and hyporeninemic hypoaldosteronism changes in renin activity, plasma aldosterone and cortisol were examined under various conditions: orthostasis and intravenous furosemide, infusion of synthetic β1–24 ACTH on two consecutive days and diurnal variations in basal hormone fluctuations.Each patient showed unmeasurably low renin activity unresponsive to orthostasis and intravenous furosemide while plasma aldosterone was below normal range.Under ACTH-infusion only marked increases in aldosterone were observed in one patient whereas cortisol responded normally in all diabetics tested.Analysis of diurnal night day fluctuations (20.00–8.00) in plasma aldosterone and cortisol revealed a close and statistically significant relationship between both hormones in each of the three patients (p<0.05–<0.001). Variations in plasma aldosterone thus were mediated through changes in endogenous pituitary ACTH. Compared with normal controls however, diurnal aldosterone curves were set at a lower level.Our results demonstrate that a reduced sensitivity of the adrenal gland to ACTH is not responsible for the observed subnormal plasma aldosterone levels in these patients. Therefore, the lack of circulating angiotensin II seems to be the causative reason of hypoaldosteronism.The exact mechanism of undetectable renin activity in these patients remains unknown.

High amylase content of neoplastic pleural and pericardial effusion probably secondary to amylase producing tumor cells: Report of 2 cases

SummaryWe report two cases of malignant pleural and pericardial effusion respectively secondary to bronchogenic carcinomas. In both effusions, a significant elevation of the Salivary-type-amylase fraction was found, while the corresponding values were normal in serum and urine. Electronmicroscopy of the malignant tumor cells from the pleural effusion showed typical electron-dense granules, suggesting zymogen granules. It is concluded that the high amylase content of the effusions was due to secretion of S-type-isoamylase by the tumor cells.

Rare forms of renal hypertension.

SummaryIn the present study 19 patients with rare forms of renal hypertension were investigated: 6 patients with renal artery aneurysm, 6 cases with unilateral hydronephrosis, 4 patients with unilateral simple renal cyst, 2 cases with coarctation of the abdominal aorta and associated renal artery stenosis and 1 patient with radiation nephritis.Renal venous renin activity (PRA) was determined in 17 of the 19 cases. Seven of these 17 (41%) patients showed significant PRA-ratios (PRA affected/PRA unaffected side ≧1.5). The percentage of positive tests was comparably high in the various subgroups except in patients with renal cyst, none of them showing lateralisation of renin secretion. Selective sampling in 2 patients with renal artery branch aneurysm revealed in both cases marked local renin oversecretion.Fifteen of the 19 patients (79%) were operated either by reconstruction surgery or nephrectomy. Four cases with a renal artery aneurysm were treated with antihypertensive drugs.Patients with unilateral hydronephrosis showed the best response to surgery in terms of cure rate (3 cured, 3 improved), whereas blood pressure normalisation could not be achieved in patients with simple renal cyst (2 improved, 1 unimproved). Patients with coarctation of the abdominal aorta and associated renal artery stenosis and the 2 operated cases with renal artery aneurysm showed a good effect of corrective surgery (2 cured, 2 improved). The patient with radiation nephritis finally was improved 2 years after nephrectomy.For the total group the prognostic validity of renal venous renin determination was limited. However, selective blood sampling from peripheral renal veins may be useful in cases with renal artery branch aneurysm to detect local oversecretion of renin.ZusammenfassungIn der vorliegenden Studie wurden 19 Patienten mit seltenen Formen renaler Hypertonie untersucht: 6 Patienten mit Nierenarterienaneurysma, 6 Fälle mit unilateraler Hydronephrose, 4 Patienten mit unilateraler Nierencyste, 2 Fälle mit Coarctatio aortae und assozierter Nierenarterienstenose und ein Patient mit Strahlennephritis.Die Plasma-Renin-Aktivität (PRA) im Nierenvenenblut wurde bei 17 der 19 Fälle bestimmt. 7 dieser 17 (41%) Patienten zeigten einen signifikanten Seitenunterschied (PRA betroffene/PRA nicht betroffene Seite) ≧1,5. Der Prozentsatz positiver Tests war in verschiedenen Kollektiven vergleichbar hoch. Nur Patienten mit unilateraler Nierencyste zeigten in keinem Fall einen signifikanten PRA-Quotienten. Eine superselektive Nierenvenenrenin-Bestimmung bei 2 Patienten mit Nierenarterienaneurysma der oberen Segmentarterie zeigte in beiden Fällen eine erhöhte Plasma-Renin-Aktivität im Bereiche des Oberpols.15 der 19 Patienten (79%) wurden operiert. Dabei kamen entweder plastisch rekonstruktive Verfahren oder eine Nephrektomie zur Anwendung. 4 Fälle mit Nierenarterienaneurysma wurden antihypertensiv behandelt.Patienten mit unilateraler Hydronephrose zeigten postoperativ die besten Ergebnisse (3 geheilt, 3 gebessert), während bei keinem der 4 Patienten mit unilateraler Nierencyste die Blutdruckwerte durch den operativen Eingriff normalisiert werden konnten (3 gebessert, 1 nicht gebessert). Die Patienten mit Coarctatio aortae und assozierter Nierenarterienstenose sowie die 2 operierten Fälle mit Nierenarterienaneurysma zeigten alle ein gutes Ansprechen auf den gefäßrekonstruktiven Eingriff (2 geheilt, 2 gebessert). Der Patient mit Strahlennephritis schließlich war 2 Jahre nach Nephrektomie gebessert.Im Gesamtkollektiv unserer operierten Patienten war die prognostische Aussagekraft der Nierenvenenreninbestimmung beschränkt. Allerdings erwies sich die selektive Nierenvenenreninbestimmung bei Patienten mit einem Aneurysma einer Nierensegmentarterie als nützlich zur Entdeckung lokaler Reninüberproduktion.

Häufigkeit und Bedeutung von Nierenarterienstenosen bei Patienten mit peripherer arterieller Verschlußkrankheit

SummaryIn order to evaluate the prevalence of renal artery stenoses and the coincidence with hypertension, in this study 110 patients (24 women, 86 men, mean age 63.2±8.6 years) underwent retrograde aortography for reason of symptomatic arteriosclerosis obliterans of the lower limb arteries. In 18 (16.4%) patients renal artery stenoses by which the lumen was narrowed for more than 30% and in 2 (1.8%) patients occlusions of one renal artery were found, all of which seemed to be of arteriosclerotic origin. 12 (60%) patients with renal artery stenoses or occlusions showed arterial hypertension (RR 171±33/94±16 mmHg) inspite of adequate antihypertensive medication, 8 were normotensive even though renal artery stenoses were found angiographically. On the other hand 30 (33%) of the 90 patients without renal artery stenoses were hypertensive (RR 165±15/93±9 mmHg). These data support the observation that renal artery stenoses must not result in hypertension, but clearly indicate the higher prevalence of hypertension in patients with renal artery stenoses or occlusions. With regard to the low-risk procedure of percutaneous transluminal dilatation of renal arteries, it seems to be valuable for hypertensive patients to include renovasography into the angiographic evaluation of symptomatic lower limb arteriosclerosis.