© 1990 S. Karger AG. Basel 0028 2766/90/0563 0322S2.75/0
Nephron 1990;56:322-324
Acute Renal Failure Due to Acute Bilateral Renal Artery Thrombosis: Successful Surgical Revascularization after Prolonged Anuria R. Poniremoli', V. Rampo!dib, A. MorbidellF. F. Fiorinia, A. Remise'', G. Gariboito“ "Section of Nephrology, Istituio Scientifico di Medicina Interna University of Genoa: hIstituto di Chirurgia Generale e Cardiovascolare, University of Milan. Italy
Key Words. Bilateral renal artery thrombosis • Acute renal failure • Revascularization, surgical
Introduction Atherosclerotic thrombosis of renal arteries is an un common cause of acute renal failure since the occlusion is rarely both bilateral and complete [I]. This condition is usually encountered in the elderly in the presence of diffuse atherosclerotic disease but is rare in young pa tients especially in women. Artery occlusion is followed by ischemic changes and necrosis of kidney tissues. Only a few cases have been described so far in middle-aged patients in whom renal function recovered after surgical treatment [2-4]. We report a case of a young female patient presenting with acute renal failure due to atherosclerotic thrombosis of the abdominal aorta involving both renal arteries in which kidney revascularization performed after 42 days of anuria resulted in restoration of kidney perfusion and renal function.
Case Report A 39-year-old woman was referred to our hospital because of acute renal failure. She had been anuric for the previous 5 weeks and was receiving hemodialytic treatment. She was a heavy smoker but had no history of hypertension. During the previous 2 years she reported the onset of symptoms possibly related to claudicatio intermittens of the legs. Six weeks earlier the patient was admitted to another hospital because of
diffuse abdominal pain and hypertension and received treatment with angiotensin-converting enzyme inhibitors (enalapril 20 mg/ day); 3 days later she complained of bilateral flank pain and devel oped acute renal failure with anuria. Ultrasound scan showed normal-size kidneys and no sign of urinary tract obstruction. Serum creatinine rose to 8.6 mg/dl and hemodialysis was started. On admission to our hospital physical examination revealed a systolic murmur on the mesogastrium; lower limb pulses were feeble but still present. Blood pressure was 140/90 mm Hg, heart rate 76 beats/min. Serum creatinine was 10 mg/dl. blood urea nitrogen 61 mg/dl. glucose 86 mg/dl, Na 136 mF.q/1, K 4.7 mEq/l, Ht 39.9%, Hb 9.8 g/dl. platelets 384,000/mm1, cholesterol 167 mg/dl, and triglycerides 167 mg/dl. A renal biopsy of the left kidney showed glomeruli with only minimal ischemic changes and areas of focal tubular necrosis. Digital subtraction angiography (DSA) showed complete thrombosis of the abdominal aorta from the inferior mesenteric to the iliac arteries with complete occlusion of both renal arteries. The right renal artery was distally revascularized via colla teral capsular vessels and minimum blood flow to the kidney was maintained: the left kidney could not be visualized (fig. I). Blood supply to the lower limbs was provided by collateral channels. The patient was referred to the surgical department and 42 days after the onset of anuria underwent surgical revascularization. At operation both kidneys appeared to be of normal size (right longitudinal diameter 10.2 cm and left 9.7 cm); the left one looked white and ischemic. No pulse was palpable in both renal arteries. The abdomi nal aorta was opened longitudinally and a well-organized athero sclerotic thrombus removed. The same procedure was carried out in order to revascularize the renal arteries. At the end of surgery a good pulsation was appreciable in the right but not in the left renal artery. Histologic examination of the aortic wail confirmed the atheroscle rotic nature of the occlusion. Urinary llow started right after opera tion increasing to 3,200 ml during the first 24 h: serum creatinine fell
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/27/2018 5:26:12 PM
Abstract. Acute bilateral renal artery thrombosis is a rare but surgically correctable cause of acute renal failure. A middle-aged woman with acute renal failure and anuria due to atherosclerotic occlusion of the abdominal aorta and both renal arteries was surgically treated 42 days after the onset of anuria. Revascularization resulted in the reversal of renal failure and complete recovery of renal function in spite of prolonged anuria. An aggressive diagnostic and therapeutic approach is important whenever this condition is suspected.
Revascularization after Bilateral Renal Artery Thrombosis
323
Fig. 1. Digital subtraction angiography showing complete occlu sion of the abdominal aorta below the origin of the superior mesen teric artery.
Discussion Acute renal failure secondary to arterial occlusion of a solitary kidney is not uncommon [5]. However acute renal failure due to acute aortic and bilateral renal artery occlu sion is very rare, insofar as only 6 patients have been reported [2 7], The overal 1prognosis is poor. I n this series of patients, 3 died because of complications related to
Fig. 2. Postoperative digital subtraction angiography showing good canalization of the abdominal aorta and right renal artery. The left renal artery appears occluded shortly after its origin from the aorta. Both the iliac arteries are well canalized.
atherosclerosis or surgery, 2 had only partial recovery of renal function and only 1regained normal renal function. Age, extension of atherosclerotic lesions, duration of anuria and adequate development of collateral vessels seem to play a role in renal function recovery and mortal ity rate [5]. The lapse of time between the onset of acute renal failure and successful surgical revascularization has been reported to vary from 2 to 28 days [2, 3]. It is noteworthy that the patient described here was a rela tively young female: in fact atherosclerotic lesions are more often encountered in males of older age. It is of additional interest that surgical revascularization per formed after 42 days of anuria successfully restored nor
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/27/2018 5:26:12 PM
to 3.2 mg/dl on the 2nd postoperative day and dialytic treatment was interrupted. Three weeks after surgery a DSA showed good recanalization of the abdominal aorta and right renal artery while the left renal artery could not be visualized (fig. 2); serum creatinine was 1.6 mg/dl. blood pressure was 140/90 on hypotensive medical therapy (nifedipine 20 mg t.i.d.) and the patient was discharged. During the following months blood pressure progressively in creased and hypokalemia (serum potassium 2.7 mEq/l) developed. Peripheral plasma renin activity was elevated (II ng/m l/h, urinary sodium 130 mEq/day). A DSA performed 6 months after surgery showed an ostial stenosis of the right renal artery. The left kidney appeared small and functionally excluded. A percutaneous translu minal angioplasty was performed on the right renal artery without reversal of hypertension. Left nephrectomy was then performed. At the time of nephrectomy, the left kidney was small (longitudinal diameter 6.3 cm) and pale: depressed scars were visible on its surface. Microscopic examination showed sclerosed glomeruli, ex tensive tubular atrophy and interstitial fibrosis with focal areas of mononuclear infiltration. The right kidney was slightly enlarged (longitudinal diameter 11.7 cm). In the postoperative period blood pressure spontaneously normalized. During a 2-year follow up renal function has persisted to be normal (creatinine clearance ll()m l/m in)and the patient normoiensive.
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mal renal function. This can only be explained with the presence of collateral vessels which maintained kidney viability. Besides atherosclerotic disease, a role for an giotensin-converting enzyme therapy in the development of acute renal failure cannot be excluded in our patient: a sudden inhibition of the renin-angiotensin system, in a clinical setting where kidney blood flow was likely main tained by high angiotensin levels, may have caused a fall in perfusion pressure and in glomerular filtration rate [8]. In addition the reduction of blood How may have created a condition of hypercoagulability leading to complete thrombotic occlusion of vessels [9, 10]. The more severe involvement of the left renal artery by atherosclerotic lesions is in accordance with the lower incidence of narrowing lesions in the right compared to the left renal artery reported in the literature [1, 11]. This is commonly attributed to differences in angulation of renal arteries at their origin from the aorta [1, 12]. Normal kidney size (longitudinal diameter above 7-9 cm) [13] and revascular ization of the occluded renal artery via collateral vessels are good prognostic signs and have been reported to influence the recovery of renal function [14, 15]. This seems to be in accordance with the results of surgery in our patient. Unfortunately no specific data are available to estimate blood flows by collaterals to either kidney. As a matter of fact blood supply was weaker to the left kidney even though we were not able to find any anatomi cal basis for this. It has to be noted, however, that surgical revascularization was successful for the right kidney but proved technically more difficult for the left which un derwent ischemic atrophy within 6 months. In conclusion, atherosclerotic thrombosis of renal ar teries should be considered among other possible causes of acute renal failure even in middle-aged female pa tients. Since early surgical revascularization can success fully restore renal function, an aggressive diagnostic ap proach is recommended whenever this condition is su spected. A favorable long-term prognosis is suggested by the presence of adequate collateral vessels which may permit restoration of renal function even after several weeks of ischemia.
2 Rosenthal, D.; Levine, K.; Lanus, P.A.; Stanton, P.E.: A simpli fied approach for correction of bilateral renal and aortoiliac occlusive disease. J. Cardiol. Surg. 24: 181-185 (1983). 3 Johansen, K.; Voci, V.; Cohen, D.: Fleet, P.: Acute bilateral renal artery occlusion. Archs Surg. 116: 1232-1235 (1981). 4 Besarab, A.: Brown, R.S.: Rubin, M.T.; Salzman, E.: Wirthlin. K.; Steinman, T.; Atlia, R.R.: Skillman, S.S.: Reversible renal failure following bilateral renal artery occlusive disease. J. Am. med. Ass. 26:2838-2841 (1976). 5 De La Rocha, A.G.: Zorn, M.; Downs, A.R.: Acute renal failure as a consequence of sudden renal artery occlusion. Can. J. Surg. 242:218-222 (1981). 6 Shaw, A.B.: Gopalka, S.K.: Renal artery thrombosis caused by antihypertensive treatment. Br. med. J. 285:16 (1982). 7 Fogel, R.I.: Endreny, R.G.; Cronan, J.J.; Chazan, J.A.: Acute renal failure with anuria caused by aortic thrombosis and bila teral renal artery occlusion. A report a two cases. Rh. 1 Med. J. 70: 501-504 (1987). 8 Hricik, D.E.; Browning, P.J.; Kapelman, R.: Captopril-induced functional renal insufficiency in patients with bilateral renal-ar tery stenoses or renal-artery stenosis in a solitary kidney. New Engl. J. Med. 308:373 (1983). 9 Williams. P.S.; Ackrill. P.: Hendy, M.S.: Caplopril induced acute renal artery thrombosis and persistent anuria in a patients with documented pre-existing renal artery stenosis and renal failure. Post-grad. med. .1. 60: 561-563 (1984). 10 Micolau, J.B.: Zurita. J.M.C.: Guzman, A.B.: Millet. V.G.; Urioste, L.M.R.; Carles, C.P.: Diaz, J.L.R.: Essential thrombocyto sis with acute renal failure due to bilateral thrombosis of the renal artery and veins. Nephron 32:73-74 (1982). 11 Rodbard, S.: Physical factors in the progression of stenotic vascular lesions. Circulation 77:410— 417 (1958). 12 Boijsen, E.: Angiographic studies of the anatomy of single and multiple renal arteries. Acta radiol., suppl. 183, pp. 1-135 (1959). 13 Libertino. J.A.tZimman, L.: Breslin, D.J.; Swinton, N.W.; Legg, M.A.: Renal artery revascularization. Restoration of renal func tion. J. Am. med. Ass. 224: 1340-1342 (1980). 14 Lohse, J.R.; Shove, R.M.; Belzer. F.O.: Acute renal artery occlu sion, the role of collateral circulation. Archs Surg. //7 :801— 804 (1982). 15 Smith. G.T.: The renal vascular patterns in man. Urology 29:175 (1963).
References I Wasser, W.G.; Krakoff, L.R.; Haimov, M.: Glabman, S.: Mitty, H.: Restoration of renal function after bilateral renal artery occlusion. Archs intern. Med. /-i/.-1647-1651 (1981).
Giacomo Garibotto, MD Istituto Scientifico di Medicina Interna Section of Nephrology Viale Benedetto XV, 6 1-16132 Genova (Italy)
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/27/2018 5:26:12 PM
Accepted: January 2.3,1990
Nephron 1990;56:322-324
Acute Renal Failure Due to Acute Bilateral Renal Artery Thrombosis: Successful Surgical Revascularization after Prolonged Anuria R. Poniremoli', V. Rampo!dib, A. MorbidellF. F. Fiorinia, A. Remise'', G. Gariboito“ "Section of Nephrology, Istituio Scientifico di Medicina Interna University of Genoa: hIstituto di Chirurgia Generale e Cardiovascolare, University of Milan. Italy
Key Words. Bilateral renal artery thrombosis • Acute renal failure • Revascularization, surgical
Introduction Atherosclerotic thrombosis of renal arteries is an un common cause of acute renal failure since the occlusion is rarely both bilateral and complete [I]. This condition is usually encountered in the elderly in the presence of diffuse atherosclerotic disease but is rare in young pa tients especially in women. Artery occlusion is followed by ischemic changes and necrosis of kidney tissues. Only a few cases have been described so far in middle-aged patients in whom renal function recovered after surgical treatment [2-4]. We report a case of a young female patient presenting with acute renal failure due to atherosclerotic thrombosis of the abdominal aorta involving both renal arteries in which kidney revascularization performed after 42 days of anuria resulted in restoration of kidney perfusion and renal function.
Case Report A 39-year-old woman was referred to our hospital because of acute renal failure. She had been anuric for the previous 5 weeks and was receiving hemodialytic treatment. She was a heavy smoker but had no history of hypertension. During the previous 2 years she reported the onset of symptoms possibly related to claudicatio intermittens of the legs. Six weeks earlier the patient was admitted to another hospital because of
diffuse abdominal pain and hypertension and received treatment with angiotensin-converting enzyme inhibitors (enalapril 20 mg/ day); 3 days later she complained of bilateral flank pain and devel oped acute renal failure with anuria. Ultrasound scan showed normal-size kidneys and no sign of urinary tract obstruction. Serum creatinine rose to 8.6 mg/dl and hemodialysis was started. On admission to our hospital physical examination revealed a systolic murmur on the mesogastrium; lower limb pulses were feeble but still present. Blood pressure was 140/90 mm Hg, heart rate 76 beats/min. Serum creatinine was 10 mg/dl. blood urea nitrogen 61 mg/dl. glucose 86 mg/dl, Na 136 mF.q/1, K 4.7 mEq/l, Ht 39.9%, Hb 9.8 g/dl. platelets 384,000/mm1, cholesterol 167 mg/dl, and triglycerides 167 mg/dl. A renal biopsy of the left kidney showed glomeruli with only minimal ischemic changes and areas of focal tubular necrosis. Digital subtraction angiography (DSA) showed complete thrombosis of the abdominal aorta from the inferior mesenteric to the iliac arteries with complete occlusion of both renal arteries. The right renal artery was distally revascularized via colla teral capsular vessels and minimum blood flow to the kidney was maintained: the left kidney could not be visualized (fig. I). Blood supply to the lower limbs was provided by collateral channels. The patient was referred to the surgical department and 42 days after the onset of anuria underwent surgical revascularization. At operation both kidneys appeared to be of normal size (right longitudinal diameter 10.2 cm and left 9.7 cm); the left one looked white and ischemic. No pulse was palpable in both renal arteries. The abdomi nal aorta was opened longitudinally and a well-organized athero sclerotic thrombus removed. The same procedure was carried out in order to revascularize the renal arteries. At the end of surgery a good pulsation was appreciable in the right but not in the left renal artery. Histologic examination of the aortic wail confirmed the atheroscle rotic nature of the occlusion. Urinary llow started right after opera tion increasing to 3,200 ml during the first 24 h: serum creatinine fell
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/27/2018 5:26:12 PM
Abstract. Acute bilateral renal artery thrombosis is a rare but surgically correctable cause of acute renal failure. A middle-aged woman with acute renal failure and anuria due to atherosclerotic occlusion of the abdominal aorta and both renal arteries was surgically treated 42 days after the onset of anuria. Revascularization resulted in the reversal of renal failure and complete recovery of renal function in spite of prolonged anuria. An aggressive diagnostic and therapeutic approach is important whenever this condition is suspected.
Revascularization after Bilateral Renal Artery Thrombosis
323
Fig. 1. Digital subtraction angiography showing complete occlu sion of the abdominal aorta below the origin of the superior mesen teric artery.
Discussion Acute renal failure secondary to arterial occlusion of a solitary kidney is not uncommon [5]. However acute renal failure due to acute aortic and bilateral renal artery occlu sion is very rare, insofar as only 6 patients have been reported [2 7], The overal 1prognosis is poor. I n this series of patients, 3 died because of complications related to
Fig. 2. Postoperative digital subtraction angiography showing good canalization of the abdominal aorta and right renal artery. The left renal artery appears occluded shortly after its origin from the aorta. Both the iliac arteries are well canalized.
atherosclerosis or surgery, 2 had only partial recovery of renal function and only 1regained normal renal function. Age, extension of atherosclerotic lesions, duration of anuria and adequate development of collateral vessels seem to play a role in renal function recovery and mortal ity rate [5]. The lapse of time between the onset of acute renal failure and successful surgical revascularization has been reported to vary from 2 to 28 days [2, 3]. It is noteworthy that the patient described here was a rela tively young female: in fact atherosclerotic lesions are more often encountered in males of older age. It is of additional interest that surgical revascularization per formed after 42 days of anuria successfully restored nor
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/27/2018 5:26:12 PM
to 3.2 mg/dl on the 2nd postoperative day and dialytic treatment was interrupted. Three weeks after surgery a DSA showed good recanalization of the abdominal aorta and right renal artery while the left renal artery could not be visualized (fig. 2); serum creatinine was 1.6 mg/dl. blood pressure was 140/90 on hypotensive medical therapy (nifedipine 20 mg t.i.d.) and the patient was discharged. During the following months blood pressure progressively in creased and hypokalemia (serum potassium 2.7 mEq/l) developed. Peripheral plasma renin activity was elevated (II ng/m l/h, urinary sodium 130 mEq/day). A DSA performed 6 months after surgery showed an ostial stenosis of the right renal artery. The left kidney appeared small and functionally excluded. A percutaneous translu minal angioplasty was performed on the right renal artery without reversal of hypertension. Left nephrectomy was then performed. At the time of nephrectomy, the left kidney was small (longitudinal diameter 6.3 cm) and pale: depressed scars were visible on its surface. Microscopic examination showed sclerosed glomeruli, ex tensive tubular atrophy and interstitial fibrosis with focal areas of mononuclear infiltration. The right kidney was slightly enlarged (longitudinal diameter 11.7 cm). In the postoperative period blood pressure spontaneously normalized. During a 2-year follow up renal function has persisted to be normal (creatinine clearance ll()m l/m in)and the patient normoiensive.
324
Pontremoli/Rampoldi/Morbidelli/Fiorini/Ranise/Garibotto
mal renal function. This can only be explained with the presence of collateral vessels which maintained kidney viability. Besides atherosclerotic disease, a role for an giotensin-converting enzyme therapy in the development of acute renal failure cannot be excluded in our patient: a sudden inhibition of the renin-angiotensin system, in a clinical setting where kidney blood flow was likely main tained by high angiotensin levels, may have caused a fall in perfusion pressure and in glomerular filtration rate [8]. In addition the reduction of blood How may have created a condition of hypercoagulability leading to complete thrombotic occlusion of vessels [9, 10]. The more severe involvement of the left renal artery by atherosclerotic lesions is in accordance with the lower incidence of narrowing lesions in the right compared to the left renal artery reported in the literature [1, 11]. This is commonly attributed to differences in angulation of renal arteries at their origin from the aorta [1, 12]. Normal kidney size (longitudinal diameter above 7-9 cm) [13] and revascular ization of the occluded renal artery via collateral vessels are good prognostic signs and have been reported to influence the recovery of renal function [14, 15]. This seems to be in accordance with the results of surgery in our patient. Unfortunately no specific data are available to estimate blood flows by collaterals to either kidney. As a matter of fact blood supply was weaker to the left kidney even though we were not able to find any anatomi cal basis for this. It has to be noted, however, that surgical revascularization was successful for the right kidney but proved technically more difficult for the left which un derwent ischemic atrophy within 6 months. In conclusion, atherosclerotic thrombosis of renal ar teries should be considered among other possible causes of acute renal failure even in middle-aged female pa tients. Since early surgical revascularization can success fully restore renal function, an aggressive diagnostic ap proach is recommended whenever this condition is su spected. A favorable long-term prognosis is suggested by the presence of adequate collateral vessels which may permit restoration of renal function even after several weeks of ischemia.
2 Rosenthal, D.; Levine, K.; Lanus, P.A.; Stanton, P.E.: A simpli fied approach for correction of bilateral renal and aortoiliac occlusive disease. J. Cardiol. Surg. 24: 181-185 (1983). 3 Johansen, K.; Voci, V.; Cohen, D.: Fleet, P.: Acute bilateral renal artery occlusion. Archs Surg. 116: 1232-1235 (1981). 4 Besarab, A.: Brown, R.S.: Rubin, M.T.; Salzman, E.: Wirthlin. K.; Steinman, T.; Atlia, R.R.: Skillman, S.S.: Reversible renal failure following bilateral renal artery occlusive disease. J. Am. med. Ass. 26:2838-2841 (1976). 5 De La Rocha, A.G.: Zorn, M.; Downs, A.R.: Acute renal failure as a consequence of sudden renal artery occlusion. Can. J. Surg. 242:218-222 (1981). 6 Shaw, A.B.: Gopalka, S.K.: Renal artery thrombosis caused by antihypertensive treatment. Br. med. J. 285:16 (1982). 7 Fogel, R.I.: Endreny, R.G.; Cronan, J.J.; Chazan, J.A.: Acute renal failure with anuria caused by aortic thrombosis and bila teral renal artery occlusion. A report a two cases. Rh. 1 Med. J. 70: 501-504 (1987). 8 Hricik, D.E.; Browning, P.J.; Kapelman, R.: Captopril-induced functional renal insufficiency in patients with bilateral renal-ar tery stenoses or renal-artery stenosis in a solitary kidney. New Engl. J. Med. 308:373 (1983). 9 Williams. P.S.; Ackrill. P.: Hendy, M.S.: Caplopril induced acute renal artery thrombosis and persistent anuria in a patients with documented pre-existing renal artery stenosis and renal failure. Post-grad. med. .1. 60: 561-563 (1984). 10 Micolau, J.B.: Zurita. J.M.C.: Guzman, A.B.: Millet. V.G.; Urioste, L.M.R.; Carles, C.P.: Diaz, J.L.R.: Essential thrombocyto sis with acute renal failure due to bilateral thrombosis of the renal artery and veins. Nephron 32:73-74 (1982). 11 Rodbard, S.: Physical factors in the progression of stenotic vascular lesions. Circulation 77:410— 417 (1958). 12 Boijsen, E.: Angiographic studies of the anatomy of single and multiple renal arteries. Acta radiol., suppl. 183, pp. 1-135 (1959). 13 Libertino. J.A.tZimman, L.: Breslin, D.J.; Swinton, N.W.; Legg, M.A.: Renal artery revascularization. Restoration of renal func tion. J. Am. med. Ass. 224: 1340-1342 (1980). 14 Lohse, J.R.; Shove, R.M.; Belzer. F.O.: Acute renal artery occlu sion, the role of collateral circulation. Archs Surg. //7 :801— 804 (1982). 15 Smith. G.T.: The renal vascular patterns in man. Urology 29:175 (1963).
References I Wasser, W.G.; Krakoff, L.R.; Haimov, M.: Glabman, S.: Mitty, H.: Restoration of renal function after bilateral renal artery occlusion. Archs intern. Med. /-i/.-1647-1651 (1981).
Giacomo Garibotto, MD Istituto Scientifico di Medicina Interna Section of Nephrology Viale Benedetto XV, 6 1-16132 Genova (Italy)
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/27/2018 5:26:12 PM
Accepted: January 2.3,1990
