Search

A 23-year-old woman presented with disturbance of consciousness and seizure. Her blood pressure was remarkably high, and brain magnetic resonance imaging (MRI) showed high-intensity T2 signals in the bilateral basal ganglia, corpus callosum, cerebral white matter, and cortex. With the administration of angiotensin II receptor blocker, the symptoms and MRI findings improved, along with normalization of blood pressure, and a diagnosis of posterior reversible leukoencephalopathy syndrome (PRES) was made. Plasma renin activity was high, and the right kidney was severely atrophic. Results from renal and adrenal vein sampling revealed renal vascular hypertension derived from the right renal artery stenosis. The right kidney was then removed by laparoscopic nephrectomy. Pathological examination of the kidney confirmed the diagnosis of fibromuscular dysplasia (FMD). In juvenile-onset encephalitis/encephalopathy, PRES due to FMD should be included in the differential diagnosis.

A 49-year-old man with asymptomatic chronic aneurysmal dissection was admitted to our hospital. He had undergone ascending aortic replacement for type A aortic dissection 7 months before. We performed descending aortic replacement for chronic aneurysmal dissection. Renal dysfunction appeared 1 day after the operation. Contrast-enhanced computed tomography indicated that the true lumen was severely compressed by a false lumen, and that the origins of the renal artery were occluded. We performed emergency endovascular stent placement to dilate the true lumen. Immediately after this procedure, renal ischemia improved. The postoperative course was uneventful. An endovascular approach using bare stent can be a treatment option that is less invasive and prompter for a patient with renal ischemia resulting from aortic dissection.

Atherosclerosis accounts for 90% of the cases of renal artery stenosis. It is an important cause of secondary arterial hypertension by means of inducing the renin-angiotensin system, volume expansion, and sympathetic activation. Despite high procedural success rate of renal artery stenting, clinical trials have shown an inconsistent outcome about improvement in hypertension. The accurate predictors identify the good indication for renal artery stenting is clinically needed. Currently, the presence of hemodynamically critical stenosis causing renal ischemia, the presence of symptoms with undoubtedly benefit from revascularization, and the assessment of procedural risk are key factors for decision making about indication of renal artery stenting.

A 17-year-old high school boy was admitted to our hospital because of hypertension. Doppler ultrasound of the renal arteries and 3D-CT angiography showed a stenosis of the right renal artery, which was pushed against the aorta by the right crus of the diaphragm. He underwent aortography and selective renal arteriography. His right renal artery originated from the aorta at a higher level than the left renal artery, between the celiac artery and the superior mesenteric artery. Renal arteriography confirmed a 50% reduction in diameter (stenosis) of the proximal right renal artery entrapped by the right diaphragmatic crus. This pathology, unlike common renal artery stenosis, sometimes requires surgical decompression or an aortorenal bypass graft, because renal angioplasty with stenting is reported to be at risk of complication by a fracture of the stent. However, the patient rejected surgical decompression for fear of deterioration of his athletic ability. Therefore we decided to follow up his blood pressure and renal size by ultrasound every six months. Renovascular hypertension caused by diaphragmatic entrapment is a very rare disease. The diagnosis may be overlooked easily at angiography if optimal views are not obtained. It is important to display images of the renal arteries, the celiac artery and the superior mesenteric artery in both inspiration and expiration.

The patient was a 53-year-old woman who had bilateral renal arterial constriction due to Takayasu's arteritis, and developed end-stage renal failure. When transient loss of consciousness occurred in 2002, she was diagnosed with subclavian steal syndrome (SSS). The renal failure worsened in June 2004, and there was concern that the left SSS could become aggravated as a consequence of creating an arterio-venous (AV) shunt. Although peritoneal dialysis was strongly recommended, she elected to undergo hemodialysis. We confirmed that there was no reduction of cerebral blood flow using brain single photon emission computed tomography (SPECT). Right and left examinations indicated the site at which an AV shunt should be created and subsequently, the AV shunt was created on the left fore-arm. Brain SPECT findings were again confirmed after dialysis, at the time of hemodialysis induction, and again 2 years after hemodialysis induction, showing no reduction in cerebral blood flow. She has no apparent symptoms or signs of left SSS, to date. Although it is known that an SSS could arise after AV shunt creation, there has been no report of the creation of an AV shunt in a case of SSS. The present case suggests that cerebral blood flow measurement using brain SPECT is useful for evaluating cerebral hemodynamics before AV fistula creation among patients with Takayasu's arteritis.

A 53 year old male was admitted with the diagnosis of brain stem infarction. Severe stenosis of the bilateral internal carotid arteries was revealed by cerebral angiography. During the angiography, he complained of acute abdominal pain and was referred to abdominal surgical department. He was diagnosed as thrombo-embolism of the superior mesenteric artery and treated conservatively. The symptoms improved, but renal function became worse and the toe was found to be blue. Cholesterol embolism was suspected by nephrologists and thrombolytic therapy was discontinued. Steroid was administrated and LDL-apheresis was performed. The renal function was aggravating and hemodialysis was required. Emergency neurosurgical operations are sometimes performed immediately after cerebral angiography and the neuroanesthesiologists should be aware of the pathology of cholesterol embolism in perioperative management.

A decrease in urinary volume during surgery is often encountered. Usually it can be treated with intravenous fluid or diuretics. We here report a rare case of intraoperative anuria in which renal blood flow ceased totally. The patient was 36 year old female (166 cm 50 kg), who was admitted for a investigations of long-term severe hypertension of unknown origin. Radiographic examination showed no adrenal tumor but a right ovarian cyst was found and suspected to be malignant, for which oophorectomy was indicated. After epidural catheterization, general anesthesia was induced by intravenous propofol and vecuronium, and maintained with epidural lidocaine and the inhalation of isoflurane and nitrous oxide mixed with oxygen. During surgery, urinary outflow decreased gradually leading to total anuria, which was resistant to intravenous fluid and furosemide. Intraoperative pyelography was performed and both kidneys and urinary tracts were not visualized. After the surgery, when the patient returned to the ward, urine began to flow. Postoperative pathological examination of the removed ovary showed a presence of renin excreting tumor cells. The anuria was considered to be the result of transient spastic obstruction of bilateral renal arteries, presumably in response to a high level of plasma renin.

Systemic lupus erythematosus (SLE) patients, especially those with antiphospholipid antibodies, have a high incidence of arterial and venous thrombotic manifestations. However, renovascular hypertension (RVH) has been rarely reported in these patients. We describe here a 49-year-old female with antiphospholipid antibodies, complicated with RVH and presenting with sudden onset of severe hypertension, headache and nausea. She had experienced phlebitis and arterial thrombosis of the right leg. At the age of 38 years, she was diagnosed as SLE and steroid therapy was started, but she had poor drug compliance and irregularly visited our clinic. On admission, hypertension was recognized and abdominal bruit was audible on physical examination. Serological findings were compatible with SLE. She was also found to have IgG anti-cardiolipin antibody and lupus anticoagulant. Peripheral plasma renin activity (PRA) was elevated, and captopril test showed hyper-response of PRA with lowering of blood pressure. Renal echography and scintigram showed a small and poorly perfused right kidney. Selective angiography demonstrated a severe stenosis of the right renal artery at origin. A stenosis at the origin of both the superior mesenteric artery (SMA) and celiac trunk was also detected. Percutaneous transluminal angioplasty was performed, achieving successful dilatation of the right renal artery and SMA, whereas the attempt to insert the catheter into the celiac trunk was unsuccessful. After this procedure, abdominal bruit has not been audible. Following the initiation of steroid pulse therapy combined with heparin and dipyridamole, her blood pressure was gradually depressed and the test for lupus anticoagulant became negative. Therefore, RVH of this patient is thought to be associated with antiphospholipid antibodies.

Out of twenty-five patients operated on for dissecting aneurysm in our institution since January 1991, four patients had autotransplantation of the kidney. The renal autotransplantation and the segmental replacement of the descending aorta with the prosthesis were done at the same time in three of them, and segmental replacement of the distal aortic arch was followed by autotransplantation because of the postoperative acute renal failure in the other one. Postoperative renal function of simultaneously operated patients was good whereas the patient who had been treated by two-staged operation needed hemodialysis for two weeks after the autotransplantation. Postoperative scintigraphy showed fully recovered function of the autotransplanted kidneys with enlargement. CT scan showed that the false lumen of the dissecting aorta was reduced in size with increased intraluminal clot formation. Renal autotransplantation with entry closure is easy and safe technique and assures successful operative results for the dissecting aneurysm, restoring impaired renal blood flow.

Obliterative arteriopathy is one of the major obstacles to long-term survival of human renal allografts. However, the cellular composition of obliterative arteriopathy has been incompletely characterized. We have performed immunocytochemical investigations of cellular components of obliterative arteriopathy and also investigated immunophenotypic features of proliferating smooth muscle cells in these lesions. Three renal allografts that had been removed due to rejection were available for this study. Time lapse between transplantation and removal of the renal allograft in these patients was 2 months, 5 months, and 4 years and 9 months, respectively. Tissue blocks cut from these renal allografts were fixed in methanol-Carnoy's fixative, and embedded in paraffin. Serial sections from each block were cut and used for histopathological and immunocytochemical studies. Monoclonal antibodies used for this study were as follows: anti-muscle actin antibody, HHF35; anti-smooth muscle actin antibody, CGA7; anti-vimentin antibody; anti-desmin antibody; anti-macrophage antibody, HAM56; and anti-Factor VIII-related antigen antibody. In all the allografts, obliterative arteriopathy was observed in the interlobular and arcuate arteries. In an early stage of proliferative lesions (2 months), the hyperplastic intima consisted largely of macrophages, intermixed with smooth muscle cells. At this stage, smooth muscle cells at the luminal site stained positive with HHF35, but negative with CGA7. In older lesions (5 months, 4 years and 9 months), however, the thickened intima consisted almost entirely of smooth muscle cells. At this stage, smooth muscle cells stained positive with both HHF35 and CGA7.(ABSTRACT TRUNCATED AT 250 WORDS)

A 7-year-old female was discovered to be severely hypertensive. Urinary noradrenaline excretion and plasma noradrenaline level were elevated. Plasma renin activity was markedly elevated. She was found to have a mass in the hilus of the left kidney and left renal artery stenosis. Magnetic resonance imaging (MRI) of the mass revealed an extremely bright lesion on T2 weighted image. DMSA renal scintigraphy revealed a low uptake rate (4.7%) in the left kidney. A diagnosis of extra-adrenal pheochromocytoma associated with left sided renal artery stenosis was made. The mass and left kidney were removed. Electronmicroscopic examination of the mass revealed characteristic neurosecretory granules. There was only slight fibrosis in the wall of the removed left renal artery.

A case of segmental renal arterial thrombosis occurring after bilateral surgical stripping and interruption of renal pedicle lymphatics for chyluria is presented. This case showed elevation of serum creatinine (6.6 mg/dl) and lactate dehydrogenase (1131 IU/L) on the 4th day after operation, and on the 14th day, renal scintigraphy with 99 m-Tc diethylenetriamine penta acid acetic showed bilateral marked decrease of glomerular filtration rate. Aortography and selective left renal angiography demonstrated left segmental renal thrombosis, but right renal arteries were intact on the 20th day after operation. Systemic anticoagulation therapy was performed, but left renal function was destroyed completely. Excessive and prolonged retraction of the renal artery with vascular tape may have resulted in this unfortunate complication.