eMedicine Specialties > Pediatrics: Surgery > Vascular Surgery

Renovascular Hypertension: Surgical Perspective: Differential Diagnoses & Workup

Author: Andre Hebra, MD, Chief, Division of Pediatric Surgery, Medical University of South Carolina; Professor of Surgery and Pediatrics, Medical University of South Carolina
Coauthor(s): Patrick B Thomas, MD, Fellow, Department of Pediatric Surgery, Texas Children's Hospital
Contributor Information and Disclosures

Updated: Aug 8, 2008

Differential Diagnoses

Abdominal Trauma
Nephritis
Acute Poststreptococcal Glomerulonephritis
Nephrotic Syndrome
Acute Tubular Necrosis
Neurofibromatosis
Alagille Syndrome
Patent Ductus Arteriosus
Coarctation of the Aorta
Pheochromocytoma
Heart Failure, Congestive
Polycystic Kidney Disease
Hyperaldosteronism
Takayasu Arteritis
Hyperthyroidism
Thyroiditis
Kawasaki Disease
Williams Syndrome
Kidney Transplantation
Wilms Tumor
Multicystic Renal Dysplasia

Other Problems to Be Considered

Adrenal tumor
Aldosteronoma
Aortic insufficiency
Arterial hypoplasia
Stroke
Cushing disease
Cushing syndrome
Essential hypertension
Fibromuscular dysplasia
Increased intracranial pressure
Intracranial mass
Irradiation
Moyamoya disease
Renal cyst
Renal failure
Renal hypoplasia
Renal parenchymal disease
Renovascular hypertension
Retinopathy
Thrombosis
Umbilical catheter embolism

Workup

Laboratory Studies

  • Basic diagnostic tests for pediatric renovascular hypertension should accomplish 2 things.
    • Because the most common medical cause of hypertension in children is renal disease, the aim in initial testing should be the detection of unsuspected renal parenchymal disease.
    • Secondly, tests should identify the presence of end-organ damage due to the hypertension.
  • The 1987 Report of the Second Task Force on blood pressure control in childhood recommends a fasting lipid profile in patients with findings suggestive of essential hypertension to evaluate atherosclerotic cardiovascular disease.3 The report also recommends the following initial tests in children with hypertension:
    • CBC count
    • Urinalysis
    • Urine culture (all girls, selected boys)
    • Serum electrolyte levels (sodium, potassium, chloride, and total carbon dioxide)
    • BUN levels
    • Serum creatinine levels
  • Remember that the renal function test results are frequently normal in children with renovascular disease, even when the lesions are bilateral.
  • Findings on a 24-hour urine study should also be within the reference range in renovascular hypertension.
  • CBC count, serum electrolyte levels, BUN levels, and serum creatinine levels should indicate whether a pattern of renal function impairment or a pattern of aldosteronoma is present.
  • Measure a 24-hour urine sample for electrolytes, creatinine, vanillylmandelic acid, catecholamines, 17-hydroxy steroids, and 17-keto steroids. Results should rule out the possibility of a medullary or cortical tumor.
  • The erythrocyte sedimentation rate is a good indicator of active arteritis.
  • Elevation of peripheral or renal vein plasma renin activity has been used to diagnose unilateral renal disease and predict surgical curability. However, an elevated level does not establish the cause of hypertension, and plasma renin levels that are within the reference range do not rule out renovascular disease.
    • Renal vein renin ratios compare the effluent activity of each kidney. Ratios greater than 1.5 are suggestive of functionally important renovascular disease. Volume depletion exaggerates reduced renal perfusion and may increase the ratio of renal vein renins in asymmetric disease.
    • One study found that nearly 90% of renal artery disease was detected when pretreated with furosemide. However, these findings can also be misleading, especially in bilateral disease.

Imaging Studies

  • When renovascular hypertension is suspected, the criterion standard for diagnosis is renal arteriography. Because this is a very invasive procedure, performing less specific tests to modify the physician's suspicion of renovascular disease is frequently necessary before submitting the patient to this test. The following studies are useful in the assessment of patients with suspected renovascular hypertension.
    • Ultrasonography: Most authors think that radiographic studies should begin with Doppler ultrasonography of the kidneys and abdomen. This is useful in identifying renal disease and abdominal masses. In renal artery stenosis, ultrasonography often reveals a slowing and dampening of systole distal to the stenosis. Renal ultrasonographic findings are insufficient to rule out the need for angiography.
    • Renal scanning: Intravenous pyelography may be useful in detecting unilateral lesions, but is often unhelpful when bilateral disease is present. Many think that intravenous pyelography is an unnecessary part of the evaluation because results are often inaccurate in children. Likewise, technetium-99m (99m Tc) scanning, diethylenetriamine pentaacetic acid (DTPA) renal scanning, and other radionuclide studies may be misleading in bilateral renovascular hypertension. However, some think that DTPA or99m Tc dimercaptosuccinic acid (DMSA) scanning is helpful in identifying patients at increased risk for renovascular hypertension when performed before and after the administration of the ACE inhibitor, captopril. Decreased function after treatment with captopril indicates a high likelihood of renovascular stenosis. If the scan findings remain normal, renovascular disease is not ruled out.
    • Intravenous digital subtraction angiography (DSA): Intravenous DSA has also been suggested as a means of identifying renovascular disease. Unfortunately, this test is dependent on the skill of the individual interpreting the radiograph, and image quality is diminished by patient or intestinal motion, gas, overlying vessels, and poor cardiac output. The use of abdominal pressure and glucagon can reduce interference from gas and intestinal motion.
    • Renal arteriography: Selective renal arteriography is the only reliable means to document renal artery stenosis. This test is still considered the criterion standard for diagnosis of renovascular hypertension. Renal arteriography is necessary whenever surgery or percutaneous transluminal angioplasty is anticipated. Adding digital subtraction technology to renal arteriography requires one half the volume of dilute contrast medium of standard arteriography, with comparable results. Use abdominal pressure and glucagon to prevent bowel motion and gas from affecting the image quality.
    • Magnetic resonance angiography (MRA), CT angiography, and spiral angiography: MRA, CT angiography, and spiral angiography are newer studies that hold a lot of promise for diagnosis and evaluation of renovascular hypertension. Unfortunately, they have not yet been sufficiently investigated for use in children with renovascular disease. At present, interpretation of the images is technically difficult, and their usefulness appears limited to imaging of main vessels.
  • Chest radiography and echocardiography may be helpful in differentiating left ventricular failure from chronic hypertension.

Other Tests

  • ECG may be helpful in differentiating left ventricular failure from chronic hypertension.

Histologic Findings

  • Because many of the lesions in FMD occur at the renal artery orifice, obtaining a good histologic sample is frequently difficult.
  • Evaluation of stenotic lesions invariably reveals the characteristic FMD in the medial or perimedial muscular layers associated with varying degrees of intimal hyperplasia.

More on Renovascular Hypertension: Surgical Perspective

Overview: Renovascular Hypertension: Surgical Perspective
Differential Diagnoses & Workup: Renovascular Hypertension: Surgical Perspective
Treatment & Medication: Renovascular Hypertension: Surgical Perspective
Follow-up: Renovascular Hypertension: Surgical Perspective
Multimedia: Renovascular Hypertension: Surgical Perspective
References
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References

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Further Reading

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Keywords

renovascular hypertension, renal vascular hypertension, renal artery stenosis, renal causes of hypertension, fibromuscular dysplasia, FMD, fibromuscular hyperplasia, midaortic syndrome, neurofibromatosis, renal hypoplasia, arteritis, aortoarteritis, Takayasu arteritis, Williams syndrome, subisthmic coarctation, Moyamoya disease, Takayasu arteritis, Kawasaki disease, vasculitis, vascular trauma, renal artery thrombosis, anastomotic stenosis, renal ischemia, retinopathy, headaches, dizziness, confusion, seizures, stroke

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Contributor Information and Disclosures

Author

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

Medical Editor

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.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

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.

CME Editor

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; Pfizer Honoraria Consulting

Chief Editor

Mary C Mancini, MD, PhD, Professor, Department of Surgery, Louisiana State University Health Sciences Center
Mary C Mancini, MD, PhD is a member of the following medical societies: American Heart Association, American Medical Association, American Thoracic Society, Association for Academic Surgery, Association for Surgical Education, International College of Surgeons, International Society for Heart and Lung Transplantation, New York Academy of Sciences, Phi Beta Kappa, and Southern Thoracic Surgical Association
Disclosure: Nothing to disclose.

 
 
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