高血压英文ppt精品课件renal artery stenosis an important cause of

Renal Artery Stenosis: An important cause of hypertension Dr Claire Hathorn SpR, RHSC Edinburgh 11th May 2010 Presentation 3 year old girl Well Minor intercurrent illness A371:1453-1463 Anatomic distribution of renal artery stenosis in children: implications for imaging Cinncinnati Childrens Hospital,1993-2005 24 stenoses identified in 21 children, R=L 12 male, mean age 9yrs 3mths (30 mths 18 yrs) No co-morbidities 90% children had a single stenosis 75% lesions located in branch / accessory arteries Vo et al. Pediatric Radiology 2006;36:1032 Clinical Features Schroff et al. Angioplasty for renovascular hypertension in children: 20 year experience. Pediatrics 2006;118:268-275 Presenting Feature No. n=33 Incidental finding 9 Cardiac (CCF, palpitations, murmur) 7 Headache +/- vomiting 118:268-275 Investigation Doppler ultrasound Measurement of plasma renin activity Captopril plasma renin test Renal vein sampling Scintigraphy: DMSA or MAG3 CT 371:1453-1463 CT Angiogram Tullus et al. Renovascular hypertension in children. Lancet. 2008;371:1453-1463 MR Angiogram Angiography With carefully selected patients, 40% RAS Important therapeutic opportunity Visualisation of abdominal vessels Angiography: Indications Tulles et al. (2008) BP 95th centile not well-controlled on 2 drugs Other cause not identified Vo et al. (2006) Unexplained persistent HT 95th centile Shahdadpuri et al. (2000) BP 99th centile not controlled with 1 drug Angiography abnormal in 43% patients A 4-year-old hypertensive boy Vo et al. Anatomic distribution of RAS in children. Pediatric Radiology 2006;36:1032 14 yr old hypertensive girl Vo et al. Anatomic distribution of RAS in children. Pediatric Radiology 2006;36:1032 Medical Management Anti-hypertensives Multiple often required Adequate BP control often not possible Adverse effects common Avoid ACE inhibitors 371:1453-1463 Angioplasty for renovascular hypertension in children: 20 year experience Retrospective review from GOS All children undergoing PTA 1984-2003 Only stenoses in main or large segmental arteries Excluded transplants 118:268-275 Angioplasty for renovascular hypertension in children: 20 year experience Final outcomes of PTA: 18 (55%) improved BP control 11/13 (85%) if isolated main RAS 10 (30%) ongoing HT despite adequate dilation 5 (15%) PTA unsuccessful Restenosis in 2/27 native renal arteries after balloon dilatation, 7/19 of stented arteries 6 (18%) suffered complications, incl 1 death Schroff et al. Pediatrics 2006;118:268-275 Left RAS before 118:268-275 Surgery For refractory HT when medical Rx 25(3):807-813 Results of surgical treatment for RVH in children: 30 yr single centre experience 12 months post-op: 16 (43%) normal BP without treatment 15 (41%) normal/improved BP on 1-4 drugs 4 (11%) unchanged 90% overall improvement Complications: Haemorrhage (5) Septicaemia (5) Chylous ascites (1) Stadermann et al. Nephrology Dialysis Transplantation. 2010;25(3):807-813 Children not amenable to Angioplasty or Surgery Diffuse abnormalities of very small intrarenal arteries Antihypertensive medication Uncontrolled on 6-7 drugs not uncommon Therapeutic trial with ACE inhibitor or angiotensin blocker warranted Tullus et al. Renovascular hypertension in children. Lancet. 2008;371:1453-1463 Suggested Investigations(Tullus 2008) Tullus et al. Renovascular hypertension in children. Lancet