Chronic Kidney Disease is associated with significant mortality and morbidity. One of the most important cause for Chronic Medical Renal Disease in patients undergoing maintainance haemodialysis is Atherosclerotic renal artery stenosis which further causes refractory (resistant) hypertension. Atherosclerotic renovascular disease is usually associated with obstructive coronary artery disease in 90% of individuals above age of 60 yrs. Atherosclerotic peripheral vascular disease, considered as a coronary artery disease equivalent, also frequently accompanies atherosclerotic renovascular disease. Thus atherosclerosis is the most common cause for macrovascular disease affecting multiple arterial territories.
A 80 year old non-diabetic hypertensive female, known case of chronic kidney disease on maintainance haemodialysis thrice a week, was brought to the casualty with history of dyspnoea NYHA Class III and retrosternal chest discomfort since 1 week. On examination, blood pressure in rt. upper limb was 200/100 mm Hg. Rt lower limb pulses were feeble. Bilateral fine crepitations were auscultated in the lungs. Left forearm showed a patent arterio-venous fistula.
Diagnosis & Treatment :
Patient was admitted to the ICU under nephrologist. ECG done showed dynamic ST Segment depression(infero-lateral ischaemia. 2-DECHO showed global Left Ventricular Dysfunction with Ejection Fraction of 35%. Chest Xray revealed pulmonary venous congestion. She was stabilised with intravenous nitrates, diuretiucs, unfractionated heparin and antihypertensive medications over a period of 2 days. On her scheduled day of haemodialysis, Coronary, Renal and Peripheral Angiography was done through rt femoral arterial access, which revealed bilateral renal artery (0steo-proximal) 90% stenosis,90% long segment Right Coronary artery Stenosis and 80% Rt common iliac artery stenosis. After discussion with the nephrologist, patient was planned for a staged angioplasty with stent to the above mentioned affected arteries. Subsequently, she underwent Rt coronary artery angioplasty with drug-eluting stent followed by the scheduled haemodialysis. After 2 days, she underwent percutaneous bilateral renal artery stenting, again followed by her scheduled dialysis and after another 2 days, she underwent percutaneous transluminal angioplasty with stenting to rt common iliac artery.
Post Treatment :
The patient showed dramatic clinical improvement with her blood pressure decreasing to a value of 150/90 mm Hg after 2-3 days. She had complete relief from angina and breathlessness.Her rt lower limb pulse regained a normal waveform gradually. She was discharged from hospital in a stable condition, on optimal medical therapy and is on regular follow up with the Nephrologist and Cardiologist.
A case study by : Dr. Nikhil Niranjan Sontakke
Department of Cardiac Sciences
Manipal Hospital, Goa