Case Report: Resistant Hypertension with Renal Artery Stenosis

Following the publication of results of the Coral Study, medical management of secondary hypertension caused by renal artery stenosis is the standard of care. The Coral Study results found no difference in blood pressure control between medical management alone and medical management plus percutaneous intervention. However, because not all patients meet the inclusion criteria of the Coral Study results, management of patients in this population should be individualized.

During a poster session at Kidney Week 2019, Jinhua Zhao, MD, of the Cleveland Veterans Administration Medical Center, Cleveland, Ohio, presented a case report of a white male, 68 years of age, with uncontrolled hypertension, hyperlipidemia, type 2 diabetes mellitus, and chronic kidney disease stage 3-4. He was taking five antihypertensives: amlodipine 10 mg daily, chlorthalidone 25 mg daily, hydralazine 50 mg three times a day, terazosin 5 mg daily at bedtime, and clonidine 0.3 mg twice a day. The patient was briefly on lisinopril; the medication was stopped following development of acute renal failure with hyperkalemia. For most of the time, his blood pressure was 180-210s/80-90s.

The work-up was significant for renin activity 27.36 ng/m/h, serum aldosterone 5.9 mg/dL. Renal ultrasound showed right kidney 10.2 cm and left kidney 7.4 cm. Severe narrowing at the right renal artery orifice that had early bifurcation was seen in angiography, involving the upper and lower branches. On left renal arteriogram, a small accessory lower pole left renal artery was visualized with complete occlusion of the main left renal artery.

Renal vein sampling was conducted three days later. The renin activity of the left renal vein was 30.62 versus 117.05 of the right renal vein; renal activity of the inferior vena cava was 41.85. The treatment decision was to revasculize the right renal artery in 1 week to avoid repeated intravenous contrast exposure in a short time period.

A 6 mm x 18 mm balloon expandable stent was placed in the dominant branch of the right renal artery. One month following stent placement, the patient’s systolic blood pressure was 140-160s mm Hg treated only with lisinopril 2 mg daily. One year later, treated with lisinopril 10 mg daily, his blood pressure was 130/70 mm Hg.

“The management of resistant hypertension due to renal artery stenosis needs to be individualized,” Dr. Zhao said.

Source: Zhao J. Management of resistant hypertension due to renal artery stenosis. of a poster presented at the American Society of Nephrology Kidney Week 2019, November 8, 2019 (Abstract FR-PO1057), Washington, DC.