Renovascular Hypertension, Surgical Treatment Medication

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

Medication Summary

Medical treatment may be necessary to control blood pressure until surgery can be performed. In fact, attempt to reduce the blood pressure prior to surgery to improve the likelihood of a good surgical outcome. After surgery, medical treatment is necessary 25-30% of the time to provide complete resolution of improved or refractory hypertension.

Adrenergic receptor blockers and diuretics are the preferred form of medication. Arterial dilators are also useful in the preoperative management of malignant hypertension. Calcium channel blockers do not seem to be as widely used, and ACE inhibitors are generally avoided because of the potential compromise to renal function.

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Adrenergic blocking agents

Class Summary

Adrenergic blockers, those working at both alpha-receptors and beta-receptors, tend to be some of the most effective medicines for prolonged treatment of renovascular hypertension. At low doses, alpha-adrenergic receptor blockers may be used as monotherapy in the treatment of hypertension. At higher doses, they may cause sodium and fluid to accumulate. As a result, concurrent diuretic therapy may be required to maintain the hypotensive effects of the alpha-receptor blockers. Beta-blockers inhibit chronotropic, inotropic, and vasodilatory responses to beta-adrenergic stimulation.

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Propranolol (Inderal)

 

Beta-adrenergic blocking agent. Renin release is enhanced by beta-receptor activation, and chronic beta-blockade consistently suppresses plasma renin activity.

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Labetalol (Normodyne, Trandate)

 

Blocks beta1-adrenergic, alpha-adrenergic, and beta2-adrenergic receptor sites.

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Metoprolol (Lopressor)

 

Selective beta1-adrenergic receptor blocker that decreases automaticity of contractions. During IV administration, carefully monitor blood pressure, heart rate, and ECG. No dosage adjustment is required with renal failure.

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Atenolol (Tenormin)

 

Selectively blocks beta1-receptors with little or no effect on beta2 types.

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Phentolamine (Regitine)

 

Alpha1-adrenergic and alpha2-adrenergic blocking agent that antagonizes circulating epinephrine and norepinephrine action, reducing hypertension that results from catecholamine effects on the alpha-receptors.

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Phenoxybenzamine (Dibenzyline)

 

Noncompetitive alpha-adrenergic blocker.

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Prazosin (Minipress)

 

Alpha-receptor blocker.

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Diuretics

Class Summary

These agents promote excretion of water and electrolytes by the kidneys. They are used to treat heart failure or hepatic, renal, or pulmonary disease when sodium and water retention has resulted in edema or ascites. They may be used as monotherapy or combination therapy to treat hypertension. Diuretics may be helpful in the medical treatment of renovascular hypertension. Thiazide diuretics are preferred.

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Hydrochlorothiazide (HydroDIURIL, Esidrix)

 

Inhibits reabsorption of sodium in distal tubules, causing increased excretion of sodium, water, potassium, and hydrogen ions.

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Arterial vasodilators

Class Summary

Arterial vasodilators may be useful in the short-term management of renovascular hypertension prior to surgery. Nitroprusside is especially useful for this purpose.

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Nitroprusside (Nitropress)

 

Produces vasodilation and increases inotropic activity of the heart. At higher dosages, it may exacerbate myocardial ischemia by increasing the heart rate.

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Renin-angiotensin inhibiting agents

Class Summary

ACE inhibitors have been used by some in the control of renovascular hypertension. However, ACE inhibitors increase the risk of decreased renal function. Although this is usually reversible, their use is generally avoided until definitive therapy has been attempted. Renal blood flow is maintained as a balance of both angiotensin-II–induced vasoconstriction and prostaglandin-mediated vasodilation. With ACE inhibitor therapy, kidney perfusion is increased and renal vascular resistance is decreased. ACE inhibitors induce vasodilation in both afferent and efferent arterioles. Glomerular filtration rate (GFR) generally increases. However, in hypoperfusion states (eg, renal artery stenosis, aggressive diuresis, decompensated congestive heart failure), GFR is likely to fall because of unopposed prostaglandin vasodilation.

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Captopril (Capoten)

 

Prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in lower aldosterone secretion. Most commonly used ACE inhibitor.

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Enalapril (Vasotec)

 

Competitive inhibitor of ACE. Reduces angiotensin II levels, decreasing aldosterone secretion.

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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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