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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2020  |  Volume : 31  |  Issue : 1  |  Page : 266-270
Calcified renal artery aneurism in the right kidney causing hypertension


1 Department of Pediatric Nephrology, Erciyes University Medical Faculty, Kayseri, Turkey
2 Department of Cardiovascular Surgery, Erciyes University Medical Faculty, Kayseri, Turkey
3 Department of Urology, Division of Pediatric Urology, Erciyes University Medical Faculty, Kayseri, Turkey
4 Department of Radiodiagnostics, Erciyes University Medical Faculty, Kayseri, Turkey

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Date of Submission11-Jan-2019
Date of Decision01-Apr-2019
Date of Acceptance06-Apr-2019
Date of Web Publication3-Mar-2020
 

   Abstract 


The renal artery aneurysm (RAA) is defined as a renal artery segment that is twofold dilated than normally. It is very rare in children and often asymptomatic. However, it can cause severe hypertension (HTN) and kidney failure. Herein, we report a 14-year-old boy who with RAA which was presented with back pain. His medical history was remarkable for essential HTN that was refractory to antihypertensive medications. Plain abdominal radiography revealed calcification at the right flank area. On computed tomography images, calcification surrounding the right renal artery was detected. Selective renal angiography showed totally occluded right renal artery segment. Calcified RAA was detected on the operation and removed. Two months after, blood pressure was under control, but there was no functioning right kidney on DMSA. We think that clinicians should keep in mind RAA in the differential diagnosis of treatment-resistant HTN and use other radiologic methods even if Doppler is normal.

How to cite this article:
Gunay N, Pınarbaşı AS, Dursun &, Tunçay A, Demirci D, Kahriman G, Düşünsel R. Calcified renal artery aneurism in the right kidney causing hypertension. Saudi J Kidney Dis Transpl 2020;31:266-70

How to cite this URL:
Gunay N, Pınarbaşı AS, Dursun &, Tunçay A, Demirci D, Kahriman G, Düşünsel R. Calcified renal artery aneurism in the right kidney causing hypertension. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2020 Apr 4];31:266-70. Available from: http://www.sjkdt.org/text.asp?2020/31/1/266/279951



   Introduction Top


Renal artery aneurysm (RAA) is very rarely seen in children. It is defined as a segment of the renal artery that is two-fold dilated than normally.[1] Although it is often asymptomatic, 30% of patients may have uncontrolled hypertension (HTN), shock, abdominal and flank, pain thrombosis, and hematuria.[2] It can be easily overlooked. Herein, we report a patient with severe HTN due to calcified RAA in the right kidney.


   Case Report Top


A 14-year-old boy who had been followed with essential HTN for four years, presented with a two months history of back pain. He ignored trauma. On admission, blood pressure (BP) was 170/100 mm Hg, but the physical examination was otherwise unremarkable. We could not control his BP with multiple anti- hypertensive medication including amlodipine, enalapril, and doxazosin. His medical history of the past four years revealed that he suffered from headache and was diagnosed with essential HTN with normal renal functions and radiologic evaluation, including Doppler ultra- sonography (USG) of kidneys.

On admission, urinalysis, liver, and renal function tests were normal. Plain abdominal radiography revealed a calcification measuring approximately 3 cm at the level of the right renal artery [Figure 1].
Figure 1: Plain abdominal radiography. This revealed a calcification at the level of the right renal artery.

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Renal Doppler USG documented decreased arterial blood flow in the right kidney with an abnormal Doppler waveform, which was suggestive of unilateral renal artery stenosis. To clarify the calcified lesion, an abdominal computed tomography (CT) scan was performed. On CT images and 3-dimensional (3D) reconstruction view, calcification surrounding the right renal artery [Figure 2] was detected. They also showed a small right kidney.
Figure 2: Computed tomography (a) and 3-dimensional reconstruction view (b). These revealed a calcification surrounding the right renal artery.

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Selective renal angiography (SRA) was performed, and it showed that the right renal artery also originated from the abdominal aorta as two separate segments. Stenotic segments and dilatations were observed at the distal section of the upper renal artery segment which was not suitable for balloon dilatation because of the small diameter. It was seen that the lower segment of the right renal artery provided most of the renal blood supply [Figure 3].
Figure 3: Selective renal angiography views. (a) Two segments of the renal artery were seen branching 1 cm apart from the abdominal aorta (b) Stenotic segments and dilatations at the distal section of the upper renal artery segment. (c) The lower renal artery segment.

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Since DMSA renal scan revealed a split renal function of 71.34% on the left and 29.68% on the right [Figure 4] and he had flank pain and uncontrolled HTN, he underwent surgical repair. Retroperitoneal space was reached under general anesthesia with right flank position and flank incision. Renal hilus were identified by appropriate dissection. It was seen that two renal arteries originating from the abdominal aorta with 1 cm interval provided blood supply to the upper and lower poles of the kidney. However, it was seen that the lower branch from these renal arteries was completely calcified, and the upper branch had calcifications 1 cm after separation from the aorta. The upper renal artery was cut at 1 cm distance from the aortic root and at the level of the renal hilus. A 6 mm wide 5 cm long vessel graft was placed. The normal portion of the lower renal artery at the level of renal hilus was connected by end-side anastomose in this graft. When the clamps were opened, the renal blood supply was normal, and the operation was terminated. Intraoperative Doppler examination performed after the operation showed that the perfusion of the right kidney was decreased. The resistivity index was 0.470.57. However, his BP returned to the normal value of his age within a couple of days and doxazosin was stopped. Two months after surgery, his BP was under control with enalapril and amlodipine, but there was no functioning right kidney on DMSA.
Figure 4: Renal cortical scintigraphy. This revealed split renal function of 71.34% on the left and 29.68% on the right kidney

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Informed consent was obtained from the patient’s guardian for the publication of the text and the use of the images.


   Discussion Top


Although renal parenchymal and vascular diseases are the leading causes of pediatric HTN, especially in early childhood, primary HTN is commonly seen in adolescent.[3] At the first admission of our patient, he did not have any abnormal physical examination findings and laboratory abnormality, suggesting renal vascular disorders. Renal Doppler ultrasound was also normal. Therefore, he was diagnosed and followed as primary HTN.

RAA is a very rare pathology with an estimated incidence of 0.09% on autopsy studies.[1],[2] It is classified as true or pseudo aneurysm based on the pathogenesis. While diseases such as fibromuscular dysplasia and connective tissue diseases causing thinning in the wall of the vein often cause true aneurysm, inflammation, infection, and periarterial hematoma secondary to penetrating trauma may result in pseudoaneurysm[2],[4] We could not get any history of trauma and detect symptoms or signs resembling vasculitis and connective tissue disease. There were no angiographic findings compatible with fibro-muscular dysplasia.

Pediatric RAA is often asymptomatic but occasionally can emerge with clinical symptoms such as uncontrolled HTN, shock, abdominal and flank pain, thrombosis, hematuria, and kidney failure.[2],[5] The accompanying stenosis is the main reason of HTN in patients with RAA. Kinking or torsion of the arteries and distal parenchyma embolization result in HTN in those patients.[6] In our patient, calcified RAA led to stenosis and caused uncontrolled HTN.

The diagnosis of RAA is difficult unless it is symptomatic. Renal Doppler USG is a commonly used noninvasive tool. However, it may miss the diagnosis because of its nature of highly user-dependent. Spiral CT, 3D, contrast- enhanced, magnetic resonance angiography (MRA), or digital subtraction arteriography (DSA) can be used for diagnosis. Angiography remains the gold standard for diagnosing of aneurysms within the renal arterial tree.[2],[4],[6] In the case presented here, renal Doppler USG missed RAA the first visit, and we reached exact diagnosis at last visit using CT and SRA in addition to renal Doppler USG.

The indications for interventional treatment of RAA remain controversial. In adult patient, treatment is indicated for symptomatic, enlarging, dissecting aneurysms or aneurysms larger than 2 cm, but there is no upper size limit for it in children.[4],[7] Endovascular treatment is the most preferred method in hypertensive and patients having risk for rupture.[7],[8],[9],[10] In our case, we first planned to perform balloon dilation and stenting of narrowed segment of the renal artery. Unfortunately, it was seen that the vessel was completely obstructed and the size of the vessel was not suitable for dilatation. Therefore, we decided to give him a chance for surgery to protect the residual renal function of the right kidney. Although his BP returned normal a couple of days after surgery, DMSA scan demonstrated non-functioning right kidney two months after surgical procedure.

In conclusion, RAA in children is a rare entity, and it can cause severe HTN and kidney failure secondary to renal artery stenosis. We think that clinicians should keep in mind RAA in the differential diagnosis of treatment resistant HTN and use other radio- logic methods such as BT, MRA, and DSA even Doppler USG is normal.

Conflict of interest: None declared.



 
   References Top

1.
Davis FM, Eliason JL, Ganesh SK, Blatt NB, Stanley JC, Coleman DM. Pediatric nonaortic arterial aneurysms. J Vasc Surg 2016;63:466- 76.  Back to cited text no. 1
    
2.
González J, Esteban M, Andrés G, Linares E, Martínez-Salamanca JI. Renal artery aneurysms. Curr Urol Rep 2014;15:1-9.  Back to cited text no. 2
    
3.
Flynn JT, Kaelber DC, Baker-Smith CM, et al. Subcommittee on Screening and Management of High Blood Pressure in Children. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics 2017;140:e20171904.  Back to cited text no. 3
    
4.
Cura M, Elmerhi F, Bugnogne A, Palacios R, Suri R, Dalsaso T. Renal aneurysms and pseudoaneurysms. Clin Imaging 2011;35:29- 41.  Back to cited text no. 4
    
5.
Chen S, Meng H, Cao M, Shen B. Renal artery aneurysm mimicking renal calculus with hydronephrosis. Am J Kidney Dis 2013;61: 1036-40.  Back to cited text no. 5
    
6.
Cabral AJ, Silvestre C, Loureiro H, Almeida HI. Renovascular hypertension in an 8-year- old girl. BMJ Case Rep 2013;2013. pii: bcr2013009691.  Back to cited text no. 6
    
7.
Gümüştaş S, Ciftçi E, Bircan Z. Renal artery aneurysm in a hypertensive child treated by percutaneous coil embolization. Pediatr Radiol 2010;40:1285-7.  Back to cited text no. 7
    
8.
Menéndez SA, Martín SM, Fernández SP, Fajardo JA, González JR, del Busto EF. Calcified renal artery aneurism embolization in a solitary kidney. Arch Esp Urol 2011 ;64:629- 31.  Back to cited text no. 8
    
9.
Klausner JQ, Lawrence PF, Harlander-Locke MP, et al. The contemporary management of renal artery aneurysms. J Vasc Surg 2015;61: 978-84.  Back to cited text no. 9
    
10.
Titze N, Ivanukoff V, Fisher T, Pearl G, Grimsley B, Shutze WP. Surgical repair of renal artery aneurysms. Bayl Univ Med Cent 2015;28:499-501.  Back to cited text no. 10
    

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Correspondence Address:
Neslihan Gunay
Department of Pediatric Nephrology, Erciyes University Medical Faculty, Kayseri
Turkey
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DOI: 10.4103/1319-2442.279951

PMID: 32129223

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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