Renal-artery stenosis in a patient with Takayasu's arteritis
Christian Delles,
Sven Weidner,
Hans P. Schobel and
Harald D. Rupprecht
Department of Medicine/Nephrology, University of Erlangen-Nürnberg, Germany
Keywords: anuric acute renal failure; ischaemic nephropathy; renal-artery stenosis; Takayasu's arteritis
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Introduction
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Renal-artery stenosis is the basis of ischaemic nephropathy and is associated with renovascular hypertension. In patients with renal-artery stenosis, acute renal failure may occur due to several reasons such as treatment with an angiotensin converting enzyme inhibitor or spontaneous progression of renal-artery stenosis to occlusion [1]. In patients with a solitary kidney, occlusion of the renal artery causes anuric acute renal failure. Rapid diagnosis and treatment are the cornerstones of kidney survival. Following revascularization, the underlying cause of the renal-artery occlusion has to be elucidated. We present a patient who had severe renal-artery stenosis due to Takayasu's arteritis. In such patients, further diagnostic procedures are mandatory to diagnose the extent of the disease. Appropriate local and systemic therapy has to be initiated for other organ manifestations and to prevent recurrence of the disease.
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Case
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A 35-year-old Caucasian woman was admitted with a 2-day history of anuria, nausea, and progressive dyspnoea in April 2000. Six years before, the patient had severe right-sided renal-artery stenosis. Angioplasty, stent implantation, and bypass surgery failed to improve the severe renovascular hypertension in this patient. After these procedures, only the lower one-third of the kidney was perfused on angiography, and right-sided nephrectomy was finally performed. Since then blood pressure and serum creatinine had been normal. There was no other history of severe disease in this patient.
On admission, the patient's temperature was 37.8°C, heart rate was 100 beats per min, respiration was 22 beats per min, and blood pressure was 180/100 mmHg. The patient had signs of volume overload (mild peripheral oedema, prominent jugular veins, and inspiratory crackles heard over both lungs). Radial artery pulses were not palpable, brachial artery pulse was palpable only on the right arm. A full blood count showed leukocytosis (17200/ml) but was otherwise normal. Plasma concentrations of creatinine and urea were raised (7.2 and 170 mg/dl respectively). Urinary examination revealed a pH of 6.0, a specific weight of 1.025 g/ml, and was positive for protein (+++), ketone bodies (++), bilirubin (++) and blood (+). Urinary sodium was 6.1 mmol/l. On microscopy, a few normally shaped erythrocytes, a few granular casts and plentiful epithelial cells were found in each high-power field. Ultrasound examination showed a normally sized left kidney without any sign of urinary tract obstruction. A chest X-ray showed interstitial pulmonary oedema. Since urine output was less than 100 ml per day, and the patient did not respond to high-dose frusemide i.v., venovenous haemodialysis was performed. Antihypertensive therapy with nitrendipine was initiated. One day after admission, blood pressure was 105/80 and 70/40 mmHg measured in the right and left arms respectively.
Complement factors C3 and C4 were normal, as were antinuclear and antineutrophil cytoplasmic antibodies. C-reactive protein was 2.1 mg/dl. A tuberculin test was normal. Duplex ultrasonography of the left renal artery suggested severe stenosis. Selective angiography showed complete occlusion of the renal artery. The patient underwent immediate vascular surgery with excision of the stenotic arterial segment and interposition of a Dacron graft. Post-operative recovery was uneventful, with restoration of normal kidney function within 7 days.
Histological examination of the excised renal-artery segment showed intima fibrosis, proliferation of myofibroblasts, and infiltration of lymphocytes and multinuclear giant cells predominantly in the media and around the vasa vasorum, as well as thrombotic material with almost complete occlusion of the lumen (Figure 1
).
Six weeks after the acute renal failure the patient was re-admitted for diagnostic angiography showing occlusion of the left and stenosis of the right subclavian artery (Figure 2
). The aortic arch, carotid arteries, and abdominal aorta were normal. Treatment with prednisolone for Takayasu's arteritis was initiated [2]. Angioplasty of the right-sided subclavian artery stenosis was performed. When last seen in October 2001, the patient was well; she had a serum creatinine concentration of 0.8 mg/dl and took aspirin and 7.5 mg of prednisolone per day.

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Fig. 2. Angiography showing occlusion and collateralization of the left (arrow) and stenosis of the right subclavian artery (arrowhead).
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Discussion
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This patient had acute anuric renal failure due to renal-artery stenosis in a solitary kidney. With a history of contralateral renal-artery stenosis, recurrence of this diagnosis in the remaining kidney seemed most likely. Urinary-tract obstruction was ruled out on ultrasonography, and a normal urine sediment made the diagnosis of acute glomerulonephritis unlikely. In such patients, angiography of the renal arteries is an emergency examination [3], and an immediate surgical approach leads to favourable renal outcome [4].
In our patient, the clinical finding of non-palpable radial artery pulses together with the histological finding of inflammation suggested the presence of systemic vasculitis. Abnormalities of the subclavian arteries are by far the most common angiographic manifestations of Takayasu's arteritis (93%). The involvement of renal arteries is found in 38% of patients [5]. However, there are racial differences in the pattern of vessels affected by this disease [2]. Takayasu's arteritis is a rare disease involving only large arteries, with an estimated incidence of 2.6 cases per million persons per year [2,5]. Diagnostic criteria have been established by the American College of Rheumatology [6]. With an aggressive surgical and/or angioplastic approach combined with glucocorticoid treatment, mortality due to Takayasu's arteritis is less than 10% [5]. In our patient, it is most likely that slow progression of renal-artery stenosis occurred over time with an acute thrombotic occlusion causing anuric acute renal failure. In past years, renovascular hypertension was probably not diagnosed because of the bilateral subclavian-artery stenosis suggesting low blood pressure values.
Atherosclerosis and fibromuscular dysplasia account for 90 and 10% of cases of renal-artery stenosis, respectively [1]. Renal-artery stenosis as a manifestation of systemic vasculitis is very rare. Nevertheless, some clinical and laboratory parameters such as pulseless extremities and elevated C-reactive protein levels may indicate systemic vasculitis and warrant further diagnostic procedures. Renal-artery stenosis in a solitary kidney should be considered as a cause of anuria with an excellent prognosis when revascularization is initiated early. Certain patients with renal-artery stenosis should be screened for systemic vasculitis, since only an anti-inflammatory approach can avoid or at least reduce other complications of vasculitis.
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Notes
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Correspondence and offprint requests to: Dr Christian Delles, Department of Medicine/Nephrology, University of Erlangen-Nürnberg, Krankenhausstrasse 12, D-91054 Erlangen, Germany. Email: christian.delles{at}rzmail.uni\|[hyphen]\|erlangen.de 
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References
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- Safian RD, Textor SC. Renal-artery stenosis. N Engl J Med2001; 344: 431442[Free Full Text]
- Numano F, Okawara M, Hyoe I et al. Takayasu's arteritis. Lancet2000; 356: 10231025[ISI][Medline]
- Towne JB, Bernhard VM. Revascularization of the ischemic kidney. Arch Surg1978; 113: 216218[Abstract]
- Teoh MK. Takayasu's arteritis with renovascular hypertension: results of surgical treatment. Cardiovasc Surg1999; 7: 626632[ISI][Medline]
- Kerr GS, Hallahan CW, Giordano J et al. Takayasu arteritis. Ann Intern Med1994; 120: 919929[Abstract/Free Full Text]
- Arend WP, Michel BA, Bloch DA et al. The American College of Rheumatology 1990 criteria for the classification of Takayasu arteritis. Arthritis Rheum1990; 33: 11291134[ISI][Medline]
Received for publication: 6.11.01
Accepted in revised form: 25. 1.02