Renovascular Hypertension, Surgical Treatment Clinical Presentation

  • Author: Andre Hebra, MD; Chief Editor: Mary C Mancini, MD, PhD   more...
 
Updated: Aug 8, 2008
 

History

  • Patients may be asymptomatic, and hypertension may be discovered during routine examination or preparation for surgical treatment of another problem.
  • In most studies, more than one half of children who were hypertensive were also asymptomatic or their hypertension was discovered during a routine examination.
  • When present, symptoms are nonspecific and are often related to the organ systems most affected by hypertension.
    • The most common symptom of renovascular hypertension seems to be headache.
    • Other neurologic symptoms of renovascular hypertension include changes in mental status, vision changes, vomiting, seizures, coma, encephalopathy, hyperexcitability, and hyperirritability.
    • Symptoms of resulting congestive heart failure may also be present, such as decreased energy, edema, and shortness of breath.
    • In patients with abdominal aortic narrowing, claudication may be present.
    • Some children have anorexia, and infants or young children often present with failure to thrive.
    • Occasionally, patients have oliguric renal failure.
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Physical

  • Upon physical examination, patients have a blood pressure elevation above the 95th percentile for their age, sex, and height. Generally, children with blood pressures greater than 140/100 mm Hg are thought to be more likely to have secondary hypertension, and renovascular hypertension is more likely in children with higher blood pressure.
  • Eye examination may reveal retinopathy and retinal hemorrhages.
  • Patients with heart failure may present with tachypnea, cardiomegaly, and vasomotor instability leading to mottling and acrocyanosis.
  • Lower extremity pulses may be diminished with aortic coarctation, whether thoracic or abdominal.
  • An enlarged liver may be palpated, and an abdominal bruit may be auscultated.
  • Patients with tumors impinging on renal vasculature may present with an abdominal mass in the area of the kidney.
  • Rarely, signs or symptoms of visceral artery involvement are present because of the extensive collateralization that occurs.
  • Café au lait macules are classic in the presentation of neurofibromatosis. Patients with neurofibromatosis may also have macrocephaly, neurofibromas, dermal neurofibromas, and axillary freckling.
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Causes

Renovascular hypertension implies the cause of the elevated blood pressure is decreased arterial inflow to the kidneys. This results in activation of the renin-angiotensin system, with the development of systemic hypertension. Some congenital disorders may lead to renovascular hypertension, including arterial hypoplasia (as observed in multicystic renal dysplasia), neurofibromatosis, and Williams syndrome. The focus of this article is on the disease processes that most commonly cause renovascular hypertension in children.

  • More commonly, renovascular disease in children is considered an acquired disease. FMD is the most common form of acquired renovascular hypertension. Its incidence varies geographically, but in the United States, it is the most common cause of secondary hypertension in children.
  • Other forms of acquired renovascular hypertension include subisthmic coarctation, Moyamoya disease, Takayasu arteritis, Kawasaki disease, vasculitis, vascular trauma, renal artery thrombosis, tumors, midaortic syndrome, or anastomotic stenosis (such as posttransplantation).
    • Trauma or kidney transplantation can lead to scarring or anastomotic lesions that produce renovascular constriction.
    • Although Takayasu arteritis and Kawasaki disease occasionally lead to FMD, the cause of FMD is not always known.
  • Often, the cause of renovascular disease is unknown. Umbilical catheters in newborns, especially those born prematurely, may result in embolization of the renal vasculature. Radiation therapy of tumors in the renal area may lead to renovascular hypertension.
  • Multicystic renal dysplasia is commonly encountered in newborns. Prenatal detection by screening ultrasonography is common. These lesions are rarely bilateral and are usually associated with ipsilateral ureteral atresia. Hypertension and recurrent infections can result from this condition. As previously mentioned, multicystic dysplastic kidneys are not discussed in this article.
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Contributor Information and Disclosures
Author

Andre Hebra, MD  Chief, Division of Pediatric Surgery, Professor of Surgery and Pediatrics, Medical University of South Carolina College of Medicine

Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, and Southern Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Patrick B Thomas, MD  Fellow, Department of Pediatric Surgery, Texas Children's Hospital

Patrick B Thomas, MD is a member of the following medical societies: American Medical Association and South Carolina Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Jonah Odim, MD, PhD, MBA  Senior Medical Officer, Transplantation Immunology Branch, Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health

Jonah Odim, MD, PhD, MBA is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Physician Executives, American College of Surgeons, American Heart Association, American Society for Artificial Internal Organs, American Society of Transplant Surgeons, Association for Academic Surgery, Association for Surgical Education, Canadian Cardiovascular Society, International Society for Heart and Lung Transplantation, National Medical Association, New York Academy of Sciences, Royal College of Physicians and Surgeons of Canada, Society of Critical Care Medicine, and Society of Thoracic Surgeons

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

John Myers, MD  Director, Pediatric and Congenital Cardiovascular Surgery, Departments of Surgery and Pediatrics, Professor, Penn State Children's Hospital, Milton S Hershey Medical Center

John Myers, MD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Cardiology, American College of Surgeons, American Heart Association, American Medical Association, Congenital Heart Surgeons Society, Pennsylvania Medical Society, and Society of Thoracic Surgeons

Disclosure: Nothing to disclose.

Daniel Rauch, MD, FAAP  Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine

Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine

Disclosure: Baxter Honoraria Consulting

Chief Editor

Mary C Mancini, MD, PhD  Professor and Chief, Cardiothoracic Surgery, Department of Surgery, Louisiana State University Health Sciences Center-Shreveport

Mary C Mancini, MD, PhD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic Surgeons, and Southern Surgical Association

Disclosure: Nothing to disclose.

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Aortogram of a 4-year-old child with renovascular hypertension caused by stenosis of the left renal artery. Note that the left kidney has 2 renal arteries, and the artery to the superior pole has stenosis.
Close-up view of the same arteriogram described above. The stenotic lesion begins at the ostium of the left superior renal artery. This lesion was caused by fibromuscular dysplasia and did not respond well to balloon angioplasty.
Operative photograph of the patient described above. The patient underwent aortorenal bypass using a reinforced saphenous vein graft. The inferior pole renal artery was preserved.
Aortogram of an 8-year-old child with neurofibromatosis and renovascular hypertension caused by right renal artery stenosis.
Operative photograph of the patient shown above. An aortorenal bypass was performed using saphenous vein graft reinforced with Dacron. The aorta is completely exposed as observed in this picture, and the graft is visible inferior to the native renal artery.
Although nephrectomy is rarely indicated in the treatment of renovascular hypertension in children, it can be safely performed using modern pediatric surgical laparoscopy technique. This 3-month-old child with renal dysplasia and refractory hypertension underwent laparoscopic nephrectomy. The photograph illustrates the patient positioning and the placement of small trocars at the time of the nephrectomy. The dysplastic kidney was easily removed through a slightly enlarged umbilical incision.
Same patient shown above. The photograph was taken immediately after laparoscopic nephrectomy. This patient was discharged from the hospital 2 days after surgery. This approach eliminates the need for large incisions and facilitates recovery from surgery, minimizing pain and length of hospital stay.
 
 
 
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