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.

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Transcript of 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.

Page 1: 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.

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

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

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Persistent dizziness for 1 day

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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

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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

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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

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

cigarette: denied Over-the-counter medication or chinese

herb: nil

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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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

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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

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

renal insufficiency

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

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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

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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

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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

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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

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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.

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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

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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

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

unless combined with judicious use of iodinated contrast

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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

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Medical therapy Lifestyle interventions:

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

calcium through low fat dairy products

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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

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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

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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%

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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) ??

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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

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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.

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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.

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Left kidney: 9.9 cm

Right kidney: 7.7 cm

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

◦ Balloon dilatation procedures: 56% residual stenosis

◦ Stenting: 5% residual stenosis