ESKD with Renal Artery Stenosis

Introduction: Atherosclerosis is the leading cause of renal artery stenosis accounting for 90% of all renovascular lesions. Complications that arise secondary to renal artery stenosis can include hypertension, ischemic nephropathy, and destabilizing cardiac syndrome. In patients with a single functioning kidney, these complications can lead to rapidly declining kidney function. Patients can present from a spectrum of hypertension, acute kidney injury, or worsening chronic kidney disease. Case Description: A 71-year-old Caucasian woman with history of hypertension, atrophic right kidney, and chronic kidney disease stage IIIb A1 was evaluated for uncontrolled hypertension. She presented for second opinion regarding hypertension and kidney disease. Her blood pressure was 190/90 and eGFR at 36 cc/min which appeared to be her baseline for several years. Workup for primary hyperaldosteronism was negative and doppler of the renal arteries was negative. Five months later the patient was admitted through the emergency room with a creatinine of 13 mg/dL on routine screening. She was hypotensive and had melena. Renal angiography revealed total occlusion of the renal arteries bilaterally and she was initiated on hemodialysis. Over time she became nonoliguric, requiring less dialysis time and ultrafiltration. She was referred to a vascular surgeon to re-evaluate her left renal artery. Repeat aortogram revealed >90% left ostial stenosis with a greater than 70% proximal renal artery stenosis. She underwent renal artery angioplasty and stenting. She was able to discontinue dialysis 11 months after her start date. She has remained dialysis free for the last 7 months with eGFR at 33 cc/min and tolerating the use of Valsartan. Discussion: Multiple studies have been designed to evaluate the role of renal artery stent placement in chronic kidney disease patients with renal artery stenosis. Limited small retrospective studies have been performed to evaluate the role of renal stenting in dialysis patients. We believe the patient had acute tubular necrosis with a single partially functioning left kidney with renal artery stenosis that recovered over time. The initial angiogram failed to demonstrate the patency of the left renal artery. We would like to bring attention to the importance of evaluating the urine output as a marker for renal flow in spite of a false reporting of occlusion of the renal artery on angiogram.