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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 3  |  Issue : 2  |  Page : 68-70

Transcatheter unilateral renal artery embolization for managing refractory hypertension prior to renal transplant


1 Department of Medical Imaging, Division of Vascular Interventional Radiology, King Abdulaziz Medical City; King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
2 King Abdullah International Medical Research Center, King Abdulaziz Medical City; Department of Adult Transplant Nephrology, King Abdulaziz Medical City, Riyadh, Saudi Arabia

Date of Web Publication19-Jul-2019

Correspondence Address:
Dr. Nasser Dafer AlHendi
Department of Medical Imaging, Division of Vascular Interventional Radiology, King Abdulaziz Medical City, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AJIR.AJIR_7_19

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  Abstract 


We report a case of unilateral renal artery embolization as a management of refractory hypertension that precluded renal transplantation in a patient with end-stage renal disease and not a candidate for nephrectomy. Over the subsequent few months, the targeted blood pressure was achieved followed by noncomplicated renal transplantation.

Keywords: High-risk surgery, refractory hypertension, renal transplant, unilateral renal artery embolization


How to cite this article:
AlHendi ND, AlAklabi AS, Altheaby A, Al Zahrani Y, Arabi M. Transcatheter unilateral renal artery embolization for managing refractory hypertension prior to renal transplant. Arab J Intervent Radiol 2019;3:68-70

How to cite this URL:
AlHendi ND, AlAklabi AS, Altheaby A, Al Zahrani Y, Arabi M. Transcatheter unilateral renal artery embolization for managing refractory hypertension prior to renal transplant. Arab J Intervent Radiol [serial online] 2019 [cited 2019 Nov 20];3:68-70. Available from: http://www.arabjir.com/text.asp?2019/3/2/68/263069




  Introduction Top


Hypertension is common among patients with end-stage renal disease (ESRD) and often resistant to medical therapy.[1] The traditional treatment for severe refractory hypertension in ESRD patients is nephrectomy; however, due to the associated high risk, not all patients can undergo surgery.[2],[3],[4] Renal artery embolization (RAE) is a minimally invasive alternative to nephrectomy in the management of refractory hypertension with a lower degree of morbidity and mortality.[5],[6],[7],[8] Blood pressure control can be achieved with bilateral or unilateral RAE with less postembolization syndrome in unilateral group.[1]

We report this case of refractory hypertension managed safely with unilateral RAE before renal transplant.


  Case Report Top


We present a 35-year-old female with ESRD on regular hemodialysis. The patient has refractory uncontrolled hypertension on eight antihypertensive medications: prazosin 3 mg Q12h, labetalol 600 mg Q12h, candesartan 32 mg OD, clonidine 0.5 mg Q8h, nifedipine 120 mg OD, hydralazine 50 mg Q6h, spironolactone 50 mg OD, and furosemide 40 mg Q12h; which preclude renal transplantation and surgical nephrectomy. Over the past 2 years, she required several intensive care unit admissions for malignant hypertension requiring urgent intravenous antihypertensive medications. The patient could not complete most of her dialysis sessions due to high blood pressure that leads to the termination of dialysis and sending her to the emergency department.

Investigations for other causes of secondary hypertension, including renal artery stenosis, pheochromocytoma, Cushing's disease, and hyperaldosteronism were negative.

Unilateral RAE was done under moderate sedation and local anesthesia. The preprocedure antibiotic cover was commenced with a loading dose of ceftriaxone. Her blood pressure during admission was 212/120 mmHg.

Through the right common femoral artery, arteriography of the right and left renal arteries showed no renal artery stenosis [Figure 1]. Embolization of the interlobar branches with microcatheter was done [Figure 2] using 150–250 μ contour polyvinyl alcohol particles (Boston Scientific, Natick, USA). Post-right RAE arteriography demonstrated complete stasis [Figure 3].
Figure 1: Digital subtraction angiography of the right renal artery before embolization

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Figure 2: Digital subtraction angiography during selective catheterization of the right renal artery interlobar branches using microcatheter

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Figure 3: Digital subtraction angiography of the right renal artery after embolization

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Postprocedure blood pressure monitoring and pain management were done in intensive care unit. The patient developed postembolization syndrome manifested as flank pain, leukocytosis, and low-grade fever. The culture was taken and empirical antibiotic (Tazocin) was given while awaiting the result. She was discharged home on clonidine 0.5 mg Q6h, hydralazine 25 mg Q6h, labetalol 400 mg Q8h, and nifedipine 90 mg OD.

Her blood pressure at discharge was 138/72 mmHg. The patient stopped clonidine a week after discharge due to low blood pressure in dialysis unit, hydralazine reduced to 25 mg Q8h and labetalol also reduced to 200 mg Q12h. Blood pressure remained well controlled, and she required no admission related to hypertension over several subsequent months. Six months after RAE, she underwent a noncomplicated renal transplantation and discharged home with normal creatinine level. Since transplantation 5 months ago, the patient is doing well, blood pressure remains controlled on labetalol 200 mg Q12H and nifedipine 90 mg OD and renal functions are stable.


  Discussion Top


Hypertension is common among patients with ESRD and often resistant to medical therapy.[1] The activation of renin-angiotensin system and abnormal endothelial release of hemodynamically active compounds is important factors in the pathophysiology of refractory hypertension in patients with ESRD.[9],[10]

The traditional treatment for severe refractory hypertension in ESRD patients is open or laparoscopic nephrectomy. Open bilateral nephrectomy has a significant morbidity rate of 45%–58% and mortality rate of 0%–10% when performed in ESRD population.[2],[3],[4] Laparoscopic nephrectomy has a lower rate of complications compared to open surgery.[11],[12]

The present patient was neither a candidate for laparoscopic nor open nephrectomy due to her multiple comorbidities. Bilateral RAE is a minimally invasive alternative treatment for refractory hypertension related to ESRD in patients with multiple comorbidities that preclude open and laparoscopic nephrectomy.[5],[6],[7] Renal embolization is associated with decrease in the plasma concentration of endothelin-1 (ET-1), which is produced by different cell types, including mesangial, glomerular epithelial, and medullary collecting duct cells.[1] ET-1 is believed to contribute to blood pressure regulation, and decreasing its concentration may be responsible for the pressure reductive effect of renal embolization.[1] Therefore, effective parenchymal embolization/ablation with particulate embolic agents or alcohol is recommended. Proximal RAE with coils or plugs should be avoided as it may induce parenchymal ischemia and further activate the renin–angiotensin system.

Postinfarction syndrome is common after RAE which can manifest by flank pain, fever, nausea, and vomiting.[13] A randomized study by Mao et al.,[1] concluded that unilateral RAE is as effective as bilateral RAE in the management of refractory hypertension in ESRD patients, in addition to the advantage of less postinfarction syndrome with unilateral technique.

In the present case, the patient experienced only mild postinfarction syndrome manifested by pain, which was managed conservatively and resolved within the next 5 days.

In conclusion, the outcome of this case shows that unilateral RAE is an effective and safe therapy for the management of refractory hypertension in patients with ESRD prior to renal transplant.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mao Z, Ye C, Mei C, Zhao X, Zhang Y, Xu C, et al. Comparison of unilateral renal artery embolization versus bilateral for treatment of severe refractory hypertension in hemodialysis patients. World J Urol 2009;27:679-85.  Back to cited text no. 1
    
2.
Yarimizu SN, Susan LP, Straffon RA, Stewart BH, Magnusson MO, Nakamoto SS, et al. Mortality and morbidity in pretransplant bilateral nephrectomy: Analysis of 305 cases. Urology 1978;12:55-8.  Back to cited text no. 2
    
3.
Darby CR, Cranston D, Raine AE, Morris PJ. Bilateral nephrectomy before transplantation: Indications, surgical approach, morbidity and mortality. Br J Surg 1991;78:305-7.  Back to cited text no. 3
    
4.
Novick AC, Ortenburg J, Braun WE. Reduced morbidity with posterior surgical approach for pretransplant bilateral nephrectomy. Surg Gynecol Obstet 1980;151:773-6.  Back to cited text no. 4
    
5.
Hom D, Eiley D, Lumerman JH, Siegel DN, Goldfischer ER, Smith AD, et al. Complete renal embolization as an alternative to nephrectomy. J Urol 1999;161:24-7.  Back to cited text no. 5
    
6.
De Baere T, Lagrange C, Kuoch V, Morice P, Court B, Roche A, et al. Transcatheter ethanol renal ablation in 20 patients with persistent urine leaks: An alternative to surgical nephrectomy. J Urol 2000;164:1148-52.  Back to cited text no. 6
    
7.
Golwyn DH Jr., Routh WD, Chen MY, Lorentz WB, Dyer RB. Percutaneous transcatheter renal ablation with absolute ethanol for uncontrolled hypertension or nephrotic syndrome: Results in 11 patients with end-stage renal disease. J Vasc Interv Radiol 1997;8:527-33.  Back to cited text no. 7
    
8.
Basile A, Boullosa-Seoane E, Dominiguez-Viguera L, Certo A, Casal-Rivas M. Bilateral renal embolization in the treatment of patients with renal insufficiency and arterial hypertension: Report of a case of polycystic kidneys. Radiol Med 2002;103:555-7.  Back to cited text no. 8
    
9.
Collins CS, Eggert CH, Stanson AJ, Garovic VD. Long-term follow-up of renal function and blood pressure after selective renal arterial embolization. Perspect Vasc Surg Endovasc Ther 2010;22:254-60.  Back to cited text no. 9
    
10.
Birchem JA, Fraley MA, Senkottaiyan N, Alpert MA. Influence of hypertension on cardiovascular outcomes in hemodialysis patients. Semin Dial 2005;18:391-5.  Back to cited text no. 10
    
11.
Shoma AM, Eraky I, El-Kappany HA. Pretransplant native nephrectomy in patients with end-stage renal failure: Assessment of the role of laparoscopy. Urology 2003;61:915-20.  Back to cited text no. 11
    
12.
Fricke L, Doehn C, Steinhoff J, Sack K, Jocham D, Fornara P, et al. Treatment of posttransplant hypertension by laparoscopic bilateral nephrectomy? Transplantation 1998;65:1182-7.  Back to cited text no. 12
    
13.
Bergreen PW, Woodside J, Paster SB. Therapeutic renal infarction. J Urol 1977;118:372-4.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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