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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR  
Year : 2013  |  Volume : 24  |  Issue : 2  |  Page : 384-386
Takayasu's arteritis presenting as renovascular hypertension


Department of Nephrology and Dialysis, Civic and Di Cristina Hospital, Palermo, Italy

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Date of Web Publication26-Mar-2013
 

How to cite this article:
Cavoli GL, Tortorici C, Bono L, Ferrantelli A, Giammarresi C, Rotolo U. Takayasu's arteritis presenting as renovascular hypertension. Saudi J Kidney Dis Transpl 2013;24:384-6

How to cite this URL:
Cavoli GL, Tortorici C, Bono L, Ferrantelli A, Giammarresi C, Rotolo U. Takayasu's arteritis presenting as renovascular hypertension. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2019 Dec 11];24:384-6. Available from: http://www.sjkdt.org/text.asp?2013/24/2/384/109615
To the Editor,

Takayasu's arteritis (TA) is a chronic vasculitis involving aorta and its major branches. Stenotic lesions, thrombosis formation, and acute inflammation can destroy the arterial media and can lead to aneurysm formation. Both the etiology and the mechanism of the vascular injury are not fully known. [1] The disease is presumably the result of idiopathic autoimmune mechanism. Almost all patients have ischemic symptoms. However, clinical presentation may be insidious and diagnosis may often be delayed. Early diagnosis and treatment are associated with a better prognosis.

A 40-year-old Caucasian female was admitted to our department with severe hypertension and visual disturbances in February 2006. She had undergone left nephrectomy 20 years ago for left nephrosclerosis and right renal artery balloon angioplasty for right renal artery stenosis. Since her last pregnancy, complicated by gestosis 12 years ago, she has been on regular antihypertensive therapy. On admission, her physical examination showed asymmetric radial pulses and upper arm blood pressure values were 150/90 on the left and 190/110 on the right. Vascular bruits were audible over all the major arteries. Echocardiography showed mild left ventricular hypertrophy with normal ejection fraction (EF). Examination of ocular fundus was negative for hypertensive signs and neurological examination was also unremarkable. C-reactive protein was 1.6 mg/dL (normal 0-0.5 mg/dL), Hb 9.8 g/dL, glomerular filtration rate (GFR) 79 mL/m, and proteinuria amounted to 100 mg/day. Microbiological tests and other routine parameters were unremarkable. The tests for autoantibodies and other immunological parameters were negative. There was aortic calcification in abdominal radiography and right renal artery. CT-angio study showed a wide-spread parietal thickening in aortic arch, common trunk, and common internal and external carotids; a widespread narrowing in common carotids and critical stenosis in right common carotid; right vertebral artery occlusion; upper mesenteric artery occlusion; and a critical stenosis of the celiac tripod. There were no abnormalities seen in the right renal artery and iliac axis. We diagnosed TA and started therapy with pulses of methylprednisolone, simvastatin, ticlopidine, and mycophenolate mofetil. One month later, the patient underwent balloon angioplasty with stenting, both in common carotid artery and celiac trunk. Her general condition improved and blood pressure was under control. Nowadays she feels fine and is continuing her immunosuppressant therapy.

Usually TA affects mainly young women. Initially it was described in Asian countries and its prevalence in females was reported as 10 times higher than in males. Later it was described in other groups and in different ethnic populations. Also, investigators have pointed out the variations of epidemiological, diagnostic, and clinical aspects of this disease. [2] Regarding the higher prevalence in females, it was suggested that it could be due to a possible underestimation of the number of men with TA. There is similarity in the clinical features between TA, inflammatory abdominal aortic aneurysm (IAAA), and atherosclerosis, [3] and since the latter two diseases predominate in males, misdiagnosis can occur resulting in an underestimation of the number of men with TA. A genetic predisposition supported by the highly frequent presence of the same HLA haplotype has been suggested both in TA and IAAA.

The natural history of TA shows two periods: the early phase, with various systemic symptoms (weakness, night sweats, low-grade fever, weight loss, arthralgia), and later, the phase of active vascular inflammation. During this later phase, the systemic manifestations subside and the clinical state is characterized by ischemic events. Diagnostic criteria application allows the correct diagnosis [4],[5] [Table 1] and [Table 2]. In this case, only claudication on extremities was absent. According to Takayasu Conference Tokyo in 1994, [6] this case belongs to 5 th type because of simultaneous involvement of aortic arch, carotid and vertebral arteries, abdominal aorta, celiac trunk, and upper mesenteric artery. [6]
Table 1: Criteria for diagnosis of Takayasu's arteritis (American College of Rheumatology 1990).

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Table 2: Cassification criteria for Takayasu's arteritis according to the European League Against Rheumatism (EULAR2006)

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In this report, we highlight the possibility of a clinical presentation of TA with renovascular hypertension with the clinical features of the systemic vasculitis hidden for many years. Diagnostic criteria application allowed us to make the correct diagnosis and therapy. Early institution of immunosuppressant therapy together with cardiovascular drugs results in a better prognosis. [7],[8] For this, one needs to be aware of the early clinical features of this disease and use of diagnostic criteria.

 
   References Top

1.Noris M. Pathogenesis of Takayasu's Arteritis. J Nephrol 2001;14:506-13.   Back to cited text no. 1
[PUBMED]    
2.Vanoli M, Bacchiani G, Origgi L, Scorza R. Takayasu's arteritis: a changing disease. J Nephrol 2001;14:497-505.  Back to cited text no. 2
    
3.Numano F. Vasa vasoritis, vasculitis and atherosclerosis. Int J Cardiol 2000;75:S1-8.  Back to cited text no. 3
[PUBMED]    
4.Arend WP, Michel BA, Bloch DA, et al. American College of Rheumatology 1990 criteria for the classification of Takayasu arteritis. Arthritis Rheum 1990;33:1129-34.  Back to cited text no. 4
[PUBMED]    
5.Ozen S, Ruperto N, Dillon MJ, et al. EULAR/ PReS endorsed consensus criteria for the classification of childhood vasculitides. Ann Rheum Dis 2006;65:936-41.  Back to cited text no. 5
[PUBMED]    
6.Moriwaka R, Noda M, Yajima M, Sharma BK, Numano F. Clinical manifestation of Takaysu's arteritis in India and Japan. New classification of angiographic findings. Angiology 1997;48: 369-79.  Back to cited text no. 6
    
7.Sabbadini MG, Bozzolo E, Baldissera E, Bellone M. Takayasu's Arteritis: The therapeutic strategies. J Nephrol 2001;14:525-31.  Back to cited text no. 7
[PUBMED]    
8.Daina E, Schieppati A, Remuzzi G. Mycophenolate mofetil for the treatment of Takayasu arteritis: Report of three cases. Ann Intern Med 1999;130:422-6.  Back to cited text no. 8
[PUBMED]    

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Correspondence Address:
Gioacchino Li Cavoli
Department of Nephrology and Dialysis, Civic and Di Cristina Hospital, Palermo
Italy
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DOI: 10.4103/1319-2442.109615

PMID: 23538372

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