報告者： fellow 1 陳筱惠

指導醫師：陳冠興醫師Commented by CV1 張其任醫師

Name: 張 O 嗣 Sex: female Age: 90-year-old Chart number: 487733 Date of admission: 2011/11/18

Persistent dizziness for 1 day

Underlying diseases: chronic kidney disease (stage 4), congestive heart failure, and atrial fibrillation

Dizziness with bradycardia episode at home (HR around 40bpm)

Associated S/S: no palpitation, chest pain, cold sweating, or consciousness disturbance

At ER: clear consiousness, af SVR

Hypertension (BP when OPD follow-up: 180~/70~mmHg)

Heart failure, LVEF:68%, HCVD related, atrial fibrillation rhythm

Chronic kidney disease, stage 4, eGFR: 29.4ml/min, 2011/04/24 crea: 1.64mg/dl

Obstrutive sleep apnea syndrome with restrictive lung

Asthma history Other significant systemic diseases:

denied

Doxazosin 4mg 1# bid Isosorbide-5-mononitrate cr 60mg 1# qd Furosemide 40ng 0.5# qd Aliskiren 150mg 1# qd 2011/06/28~ Exforge (Amlodipine 5mg + Valsartan

80mg) 1# bid 2011/11/15~◦ Micardis Plus (Telmisartan 40mg + HCTZ 12.5mg)

1# qd 2011/10/18~2011/11/15◦ Telmisartan 40mg

Allergy: no known allergy Alcohol: denied; betel-nut: denied;

cigarette: denied Over-the-counter medication or chinese

herb: nil

No family history of malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases

Vital signs: blood pressure: 135/58mmHg; temperature: 36.5‘C; pulse rate: 44/min; respiratory rate: 18/min

General appearance: acute ill looking Eye: conjunctiva: pale, sclera: no icteric Neck: supple, no lymphadenopathy or jugular vein

engorgement Chest: symmetric expansion

breathing sound: bilateral clear heart sound: irregular heart beats, no S3 or S4, no

murmurs Abdomen: soft, flat, no tenderness, muscle guarding, or rebounding liver/spleen: impalpable bowel sound: normoactive Extremities: no lower limb pitting edema Skin: intact, no rash

WBC 6.2x1000/ul

Hgb 8.3 g/dl

Hct 25.4 %

MCV 87 fL

PLT 159 x1000/uL

Segment 78.9 %

BUN 118.1 mg/dL

Creatinine 4.43 mg/dl

GPT 9 IU/L

Na 134 mEq/L

K 8.2 mEq/L

Ca 8.2 mg/dL

Mg 2.3 mEq/L

Tropo - I <0.01 ng/mL

Atrial fibrillation with slow ventricular rate, suspect hyperkalemia induced

Acute on chronic kidney disease, favor ARB drug effect, complicated with hyperkalemia and azotemia

Hypertension, poorly controlled Heart failure, LVEF:68%, HCVD related, atrial

fibrillation rhythm Obstrutive sleep apnea syndrome with

restrictive lung Asthma history

H/D

U/O 2020 660 740 860

BW 55.46 54.8 55.9 56.6

BUN 118.1 58.8

Crea 4.43 2.65

Na 134 138

K 8.5 5.1

Ca

P

C02 21.3

189/88mmHg

141/72mmHg

149/70mmHg

165/79mmHg

U/O 230 1630 2450 350 920

BW 69.5 59.1 58.3

BUN 68.7 73

Crea 2.82 2.45

Na 125 123

K 4.7 5.0

Ca 8.3 8.0

P 4.8 4.5

C02

190/99mmHg

159/72mmHg

186/84mmHg

206/94mmHg

186/89mmHg

Kidney echo

U/O 900 820 400 810 710

BW 57.9 57.2 59.5 60.7

BUN 51 51.4

Crea 1.87 2.63

Na 127 123

K 4.5 4.2

Ca 8.2 7.7

P 2.7 3.0

C02

201/96mmHg

181/80mmHg

145/66mmHg

179/86mmHg

156/72mmHg

Cortisol 14.1Renin 1644Aldosterone 328TSH 0.77Free T4 26.939

U/O 400 1210 700 300 400

BW 61.6 61.1 61.3 62.4

BUN 58.7 63.3 72.8

Crea 2.59 2.31 3.12

Na 123 125 126

K 4.9 5.3 5.6

Ca 8.0 8.0

P 4.7 5.5

C02 15.4 17.3

194/87mmHg

172/79mmHg

172/69mmHg

151/70mmHg

209/86mmHg

U/O 1320 2500 600 300 950

BW 61.6 60 62 62 63.1

BUN 80.4

Crea 2.65

Na 128

K 4.8

Ca 8.2

P 6.0

C02 21.1

179/82mmHg

156/76mmHg

174/84mmHg

169/82mmHg

176/75mmHg

Renin 995

U/O 2180 1400 650 200 600

BW 61.8

BUN 80.7 47

Crea 3.01 2.08

Na 123 130

K 3.9 3.8

Ca 7.9 8.7

P 5.1 2.7

C02

188/84mmHg

193/85mmHg

192/78mmHg

201/95mmHg

210/85mmHg

H/D

U/O 450 700 300 130 90

BW 58.2

BUN 58.1

Crea 3.12

Na 127

K 4.1

Ca 8.4

P 4.3

C02 22.5

203/90mmHg

191/83mmHg

204/90mmHg

174/75mmHg

172/95mmHg

U/O 100 80 150 230 0

BW 58.7

BUN 47.3

Crea 4.78

Na 127

K 4.9

Ca 7.9

P 3.6

C02 24.9

177/81mmHg

178/96mmHg

196/89mmHg

179/88mmHg

202/89mmHg

Hickman implantation

U/O 0 750 650 500 600

BW 54.9

BUN 37.5

Crea 4.83

Na 134

K 4.3

Ca 8.0

P 4.6

C02 23.7

168/74mmHg

164/87mmHg

163/69mmHg

141/74mmHg

168/76mmHg

Renal angiography

U/O 1100 1100 2250 1300 950

BW

BUN 37.9 44.5

Crea 4.92 4.57

Na 131 131

K 4.4 4.5

Ca 7.8 8.5

P 4.9 5.4

C02 23.4 22.6

197/85mmHg

151/69mmHg

168/79mmHg

122/61mmHg

161/74mmHg

Hold H/D

U/O 1450 1400

BW 50.2

BUN 36.5 19.6

Crea 2.83 1.74

Na 133 136

K 4.4 5.0

Ca 9.0 8.6

P 4.2 4.0

C02

147/81mmHg

134/64mmHg

119/54mmHg

1/17 remove hickman

Renal Artery Stenosis: Optimizing Diagnosis and TreatmentProgress in Cardiovascular Diseases 54 (2011) 29–35

1st: atherosclerotic lesions, 90% of all renovascular lesions◦ Typically in older individuals◦ An equal prevalence in men and women◦ Predominantly at or near the origin of the renal

artery and usually are associated with aortic disease

◦ May present with hypertension or renal insufficiency

2nd: fibromuscular dysplasia (FMD)◦ More often in young women◦ Usually associated with hypertension without

renal insufficiency

A limited literature addresses the clinical factors that are predictive of finding atherosclerotic RAS and that may be useful in guiding appropriate screening.

Doppler ultrasound Computed tomography angiography (CTA)

and magnetic resonance angiography (MRA) Conventional angiography

Imaging For Renovascular DiseaseSeminars in Nephrology, Vol 31, No 3, May 2011, pp 272-282

Duplex ultrasonography: screening test◦ Sensitivity: 92.5% to 98%; specificity: 96% to 98%◦ Nontoxic◦ No exposure to ionizing radiation◦ Capable and reliable◦ Major limitation: dependence on technician skill

for acquisition of adequate images; others: obesity, bowel gas, and recent food intake

Computed tomography angiography (CTA):◦ Sensitivity and specificity: > 95%◦ Multicenter Renal Artery Diagnostic Imaging

Study in Hypertension (RADISH) study SEN 64%, SPE 93%

◦ Qualitative◦ Risk of contrast nephropathy

Magnetic resonance angiography (MRA):◦ Slightly lower sensitivities and specificities than

CTA; RADISH study SEN 62%, SPE 84%◦ To measure flow, renal perfusion, and renal

function◦ Poorer spatial resolution, limited availability,

patient tolerance, and the need for extended breath-holding

◦ Nephrogenic sclerosing fibrosis associated with Gadolinium in patients with renal insufficiency

Duplex ultrasonography is inferior to MRA and CTA.

Diagnostic tests for renal artery stenosis in patients suspected of having renovascular hypertension: a meta-analysis. Ann Intern Med 2001;135:401-411.

Captopril renography:◦ Poor screening test

Dependent on comparative imaging of the right and left kidneys

The incidence of bilateral RAS is approximately 30%.◦ May be useful when trying to determine the

physiologic significance of a known intermediate stenosis

Invasive angiography: gold standard◦ Confirm the diagnosis based on prior noninvasive

testing and with the intent to perform an intervention

◦ The most commonly used methodology: intra-arterial digital subtraction angiography

◦ Complications: related to the vascular access, placement of the guidecatheter into the renal artery, balloon and stent deployment, and contrast administration

◦ Carbon dioxide (CO2) Image quality is reduced. May create greater uncertainty about lesion severity

unless combined with judicious use of iodinated contrast

Medical therapy Revascularization: balloon angioplasty +-

stenting or Surgical bypass or reconstruction

Goals:◦ Blood pressure control◦ Treatment of heart failure and/or pulmonary edema◦ Prevention of nephropathy

Medical therapy Lifestyle interventions:

◦ Dietary recommendations in atherosclerotic RAS: Increased intake of fruits and vegetables, dietary

calcium through low fat dairy products

Angiotensin-converting enzyme (ACE) inhibitors◦ Potential to induce acute hemodynamically

mediated renal failure in patients with RAS◦ Lower cardiovascular event rates (10% vs 13%)

and need for dialysis (1.5% vs 2.5%)◦ The cost of an increased risk of hospitalization for

acute renal failure (1.2 vs 0.6%) Selection bias: patients with better renal function

and/or less severe disease are treated with these agents resulting in an apparent improvement of outcome

Other agents used to control the atherosclerotic process are important for the care of patients with atherosclerotic RAS.◦ Statins: decrease death, limit lesion progression,

and promote restenosis-free survival◦ Platelet inhibitors: prevention of future

cardiovascular events

Revascularization:◦ Balloon angioplasty +- stenting:

Lesion severity, renal function, the skill level of the operators, and complication rates

◦ Surgical bypass or reconstruction: Not benefit over angioplasty High rates of adverse outcomes with surgery,

including perioperative mortality of approximately 10%

When stenting is performed, there are a number of technical factors that should be considered as part of the procedure.◦ “No touch” technique for engaging a catheter into

the renal artery reduce the risk of atheroembolism

◦ No embolic protection device is approved by the Food and Drug Administration for use in the renal artery.

◦ Abciximab (a platelet glycoprotein IIbIIIa inhibitor) ??

A “cure” of hypertension with revascularization◦ < 10% in patients with atherosclerotic RAS◦ Approximately 50% in patients with FMD

Younger patients more likely to achieve this outcome.

Consistent and sustained blood pressure–lowering effect of revascularization

Considerable controversy exists regarding the use of revascularization of atherosclerotic RAS to treat or prevent the development of ischemic nephropathy.◦ Stent revascularization in patients with ischemic

nephropathy and significant stenoses resulted in a slower rate of progression of nephropathy.

◦ In a minority of patients, an actual improvement in renal function is seen with either stenting or surgical revascularization.

FMD: balloon angioplasty◦ In a minority of FMD cases, there will be

concomitant aneurysms of the renal artery. Atherosclerotic RAS

◦ Stenting has proven superior to balloon angioplasty.

Left kidney: 9.9 cm

Right kidney: 7.7 cm

Right renal artery: occluded Left renal artery: proximal 71% stenosis

◦ Balloon dilatation procedures: 56% residual stenosis

◦ Stenting: 5% residual stenosis