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Renovascular Hypertension Differential Diagnoses

  • Author: Rebecca J Schmidt, DO, FACP, FASN; Chief Editor: Vecihi Batuman, MD, FACP, FASN  more...
 
Updated: May 13, 2016
 
 

Diagnostic Considerations

Clues to the presence of renovascular hypertension (RVHT) that might lead to serious complications (eg, stroke, renal failure, and cardiac decompensation) include the following:

  • Recurrent and otherwise unexplained flash pulmonary edema or heart failure
  • Recalcitrant hypertension that previously was controlled easily
  • Hypertension that abruptly becomes more difficult to control and requires increased antihypertensive agents
  • Slowly increasing serum creatinine levels, signifying the evolution of ischemic nephropathy

In addition to the conditions listed in the differential diagnosis, other problems to be considered include the following:

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

Differential Diagnoses

 
 
Contributor Information and Disclosures
Author

Rebecca J Schmidt, DO, FACP, FASN Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine

Rebecca J Schmidt, DO, FACP, FASN is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation, Renal Physicians Association, West Virginia State Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Muhammad R Mustafa, MD Assistant Professor of Medicine, Section of Nephrology, West Virginia University Health Sciences Center

Muhammad R Mustafa, MD is a member of the following medical societies: American Society of Nephrology, National Kidney Foundation

Disclosure: Nothing to disclose.

Chief Editor

Vecihi Batuman, MD, FACP, FASN Huberwald Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Renal Section, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, International Society of Nephrology

Disclosure: Nothing to disclose.

Acknowledgements

George R Aronoff, MD Director, Professor, Departments of Internal Medicine and Pharmacology, Section of Nephrology, Kidney Disease Program, University of Louisville School of Medicine

George R Aronoff, MD is a member of the following medical societies: American Federation for Medical Research, American Society of Nephrology, Kentucky Medical Association, and National Kidney Foundation

Disclosure: Nothing to disclose.

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.

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.

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.

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.

L Michael Prisant, MD, FACC Director of Hypertension and Clinical Pharmacology Unit, Professor of Medicine, Department of Medicine, Medical College of Georgia

L Michael Prisant, MD, FACC is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Clinical Pharmacology, American College of Forensic Examiners, American College of Physicians, American Heart Association, and American Medical Association

Disclosure: Abbott Grant/research funds Investigator; Boehringer-Ingelheim Grant/research funds Other; Eli Lilly None Investigator; Novartis None Investigator; Abbott, Boehringer-Ingelheim, Forest, Gilead, Merck, Merck/Schering-Plough, Novartis, Oscient, Sciele, SunTech Medical Consulting fee Consulting; Abbott, Boehringer-Ingelheim, Merck, Merck/Schering-Plough, Novartis, Oscient Honoraria Speaking and teaching

Sandeep S Soman, MBBS, MD, DNB Senior Staff Physician, Department of Internal Medicine, Division of Nephrology and Hypertension, Henry Ford Hospital

Sandeep S Soman, MBBS, MD, DNB is a member of the following medical societies: American College of Physicians, American Medical Association, and American Society of Nephrology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

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

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References
  1. Mehta AN, Fenves A. Current opinions in renovascular hypertension. Proc (Bayl Univ Med Cent). 2010 Jul. 23(3):246-9. [Medline]. [Full Text].

  2. [Guideline] Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the... Circulation. 2006 Mar 21. 113(11):e463-654. [Medline]. [Full Text].

  3. Stanley JC, Zelenock GB, Messina LM, Wakefield TW. Pediatric renovascular hypertension: a thirty-year experience of operative treatment. J Vasc Surg. 1995 Feb. 21(2):212-26; discussion 226-7. [Medline].

  4. Tyagi S, Kaul UA, Satsangi DK, Arora R. Percutaneous transluminal angioplasty for renovascular hypertension in children: initial and long-term results. Pediatrics. 1997 Jan. 99(1):44-9. [Medline].

  5. Williams KM, Shah AN, Morrison D, Sinha MD. Hypertensive retinopathy in severely hypertensive children: demographic, clinical, and ophthalmoscopic findings from a 30-year British cohort. J Pediatr Ophthalmol Strabismus. 2013 Jul-Aug. 50(4):222-8. [Medline].

  6. [Guideline] European Stroke Organisation, Tendera M, Aboyans V, et al. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2011 Nov. 32 (22):2851-906. [Medline]. [Full Text].

  7. [Guideline] Parikh SA, Shishehbor MH, Gray BH, White CJ, Jaff MR. SCAI expert consensus statement for renal artery stenting appropriate use. Catheter Cardiovasc Interv. 2014 Dec 1. 84 (7):1163-71. [Medline]. [Full Text].

  8. [Guideline] National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004 Aug. 114 (2 Suppl 4th Report):555-76. [Medline]. [Full Text].

  9. Roditi G. MR in hypertension. J Magn Reson Imaging. 2011 Nov. 34(5):989-1006. [Medline].

  10. Gloviczki ML, Lerman LO, Textor SC. Blood oxygen level-dependent (BOLD) MRI in renovascular hypertension. Curr Hypertens Rep. 2011 Oct. 13(5):370-7. [Medline].

  11. Textor SC, Glockner JF, Lerman LO, et al. The use of magnetic resonance to evaluate tissue oxygenation in renal artery stenosis. J Am Soc Nephrol. 2008 Apr. 19(4):780-8. [Medline]. [Full Text].

  12. Textor SC, Lerman L. Renovascular hypertension and ischemic nephropathy. Am J Hypertens. 2010 Nov. 23(11):1159-69. [Medline]. [Full Text].

  13. Textor SC, Lerman L, McKusick M. The uncertain value of renal artery interventions: where are we now?. JACC Cardiovasc Interv. 2009 Mar. 2(3):175-82. [Medline]. [Full Text].

  14. Bakris GL, Townsend RR, Flack JM, Brar S, Cohen SA, D'Agostino R, et al. 12-month blood pressure results of catheter-based renal artery denervation for resistant hypertension: the SYMPLICITY HTN-3 trial. J Am Coll Cardiol. 2015 Apr 7. 65 (13):1314-21. [Medline].

  15. Esler M. Illusions of truths in the Symplicity HTN-3 trial: generic design strengths but neuroscience failings. J Am Soc Hypertens. 2014 Aug. 8 (8):593-8. [Medline].

  16. Jensen G, Annerstedt M, Klingenstierna H, Herlitz H, Aurell M, Hellström M. Survival and quality of life after renal angioplasty: a five-year follow-up study. Scand J Urol Nephrol. 2009. 43(3):236-41. [Medline].

  17. Guzzetta PC. Arterial disease. Surgery of Infants and Children: Scientific Principles and Practice. Philadelphia, PA: Lippincott Williams & Wilkins; 1997:1722-4.:

  18. Casalini E, Sfondrini MS, Fossali E. Two-year clinical follow-up of children and adolescents after percutaneous transluminal angioplasty for renovascular hypertension. Invest Radiol. 1995 Jan. 30(1):40-3. [Medline].

  19. Jokhi PP, Ramanathan K, Walsh S, Fung AY, Saw J, Fox RS, et al. Experience of stenting for atherosclerotic renal artery stenosis in a cardiac catheterization laboratory: technical considerations and complications. Can J Cardiol. 2009 Aug. 25(8):e273-8. [Medline]. [Full Text].

  20. Leesar MA, Varma J, Shapira A, Fahsah I, Raza ST, Elghoul Z, et al. Prediction of hypertension improvement after stenting of renal artery stenosis: comparative accuracy of translesional pressure gradients, intravascular ultrasound, and angiography. J Am Coll Cardiol. 2009 Jun 23. 53(25):2363-71. [Medline].

  21. Cooper CJ, Murphy TP, Cutlip DE, Jamerson K, Henrich W, Reid DM, et al. Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med. 2014 Jan 2. 370 (1):13-22. [Medline]. [Full Text].

  22. Saad A, Herrmann SM, Crane J, Glockner JF, McKusick MA, Misra S, et al. Stent revascularization restores cortical blood flow and reverses tissue hypoxia in atherosclerotic renal artery stenosis but fails to reverse inflammatory pathways or glomerular filtration rate. Circ Cardiovasc Interv. 2013 Aug. 6(4):428-35. [Medline]. [Full Text].

  23. Noory E, Sritharan K, Zeller T. To Stent or Not to Stent? Update on Revascularization for Atherosclerotic Renovascular Disease. Curr Hypertens Rep. 2016 Jun. 18 (6):45. [Medline].

  24. Guzzetta PC, Potter BM, Ruley EJ, Majd M, Bock GH. Renovascular hypertension in children: current concepts in evaluation and treatment. J Pediatr Surg. 1989 Dec. 24(12):1236-40. [Medline].

  25. O'Neill JA Jr. Renovascular hypertension. Semin Pediatr Surg. 1994 May. 3(2):114-23. [Medline].

  26. Berkowitz HD, O'Neill JA Jr. Renovascular hypertension in children. Surgical repair with special reference to the use of reinforced vein grafts. J Vasc Surg. 1989 Jan. 9(1):46-55. [Medline].

  27. Wheatley K, Ives N, Gray R, Kalra PA, Moss JG, Baigent C, et al. Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med. 2009 Nov 12. 361(20):1953-62. [Medline]. [Full Text].

  28. Böhlke M, Barcellos FC. From the 1990s to CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) trial results and beyond: does stenting have a role in ischemic nephropathy?. Am J Kidney Dis. 2015 Apr. 65 (4):611-22. [Medline].

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Magnetic resonance angiography (MRA) showing renal artery stenosis. Courtesy of Patricia Stoltzfus, MD, Chief of Interventional Radiology, West Virginia University.
Proposed pathogenesis of renovascular hypertension.
Angiogram showing bilateral renal artery stenosis. Courtesy of Department of Radiology, Henry Ford Hospital.
After percutaneous transluminal angioplasty (right renal artery). Courtesy of Department of Radiology, Henry Ford Hospital.
After percutaneous transluminal angioplasty and stent placement (left renal artery). Courtesy of Department of Radiology, Henry Ford Hospital.
Close-up of the Palmaz stent. Courtesy of Department of Radiology, Henry Ford Hospital.
Aortogram of 4-year-old child with renovascular hypertension caused by stenosis of left renal artery. Note that left kidney has 2 renal arteries and that artery to superior pole has stenosis.
Close-up view of aortogram of 4-year-old child. Stenotic lesion begins at ostium of left superior renal artery. This lesion was caused by fibromuscular dysplasia and did not respond well to balloon angioplasty.
Operative photograph of 4-year-old child. Patient underwent aortorenal bypass with reinforced saphenous vein graft. Inferior pole renal artery was preserved.
Aortogram of 8-year-old child with neurofibromatosis and renovascular hypertension caused by right renal artery stenosis.
Operative photograph of 8-year-old child. Aortorenal bypass was performed with Dacron-reinforced saphenous vein graft. Aorta is completely exposed, and graft is visible inferior to native renal artery.
Although nephrectomy is rarely indicated in treatment of renovascular hypertension in children, it can be safely performed with modern pediatric surgical laparoscopy technique. This 3-month-old child with renal dysplasia and refractory hypertension underwent laparoscopic nephrectomy. Photograph illustrates patient positioning and placement of small trocars at time of nephrectomy. Dysplastic kidney was easily removed through slightly enlarged umbilical incision.
3-month-old child immediately after laparoscopic nephrectomy. This patient was discharged from hospital 2 days after surgery. This approach eliminates need for large incisions and facilitates recovery from surgery, minimizing pain and length of hospital stay.
 
 
 
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