Vol. 44 | No. 2 | July-December 2016 Back

Open Access

Renal Artery Stenosis in Takayasu’s Arteritis Causing Early-Onset Hypertension: A Report of Four Cases at the UP-Philippine General Hospital

Lauro L. Abrahan IV, Elleen L. Cunanan, Percy Jun G. Prieto, Jaime Alfonso  M. Aherrera, Antonio L. Faltado Jr, Maria Teresa B. Abola
Dec 2016 DOI 10.69944/pjc.928b2e6118

Abstract

Background: In foreign literature, 90% of renal artery stenosis (RAS) is atherosclerotic, while 10% is secondary  to fibromuscular dysplasia (FMD). However, an important differential for hypertension in the  young Asian population is Takayasu’s arteritis. We present four patients who initially presented  with hypertension in the young due to RAS. Clinical criteria coupled with non-invasive studies  in all four cases led to the diagnosis of Takayasu’s arteritis. All four patients had good outcomes. 

Case: Four patients (one male and three females) all presented with early-onset hypertension in the third  decade of life. Two of the females were pregnant at the time they were seen by the Cardiology  service at our institution. Physical examination of the abdomen and peripheral pulses provided  clinical clues that suggested the diagnosis of Takayasu’s arteritis. All four patients had confirmed  significant RAS on CT aortogram studies, thus explaining their elevated blood pressures. None of  them had significant elevations in serum creatinine. The patients were given varying combinations  of anti-hypertensive medications with or without prednisone to control vasculitic flares/disease  activity. All four patients had good outcomes. The two pregnant in-patients were successfully  discharged after their emergency cesarean sections, and all four went on regular follow-up at the  outpatient clinic with controlled blood pressure levels. 

Significance: This case series highlights that with the rarity of Takayasu’s arteritis, a thorough history and and conclusions physicalexamination are crucial in raising our index of suspicion for this disease as a possible cause  of RAS and secondary hypertension. This report also emphasizes the complexity of managing  pregnant patients with Takayasu’s arteritis. Early recognition, a multidisciplinary team, and  optimal medical management are the keys to successful outcomes. 

Keywords: renal artery stenosis, Takayasu’s arteritis, secondary hypertension, vasculitis.

References
  1. Weber BR, Dieter RS. Renal artery stenosis: epidemiology and  treatment. Int J Nephrol Renovasc Dis. 2014;7:169–181.
  2. Safian RD, Textor SC. Renal-artery stenosis. N Engl J Med.  2001;344(6):431–442. 
  3. Takayasu M. A case with peculiar changes of the central retinal vessels.  Acta Soc Opthal Jpn. 1908;12:554–555. 
  4. Hall S, Barr W, Lie JT, Stanson AW, Kazmier FJ, Hunder GG.  Takayasu arteritis. A study of 32 North American patients. Medicine  (Baltimore). 1985;64(2):89–99. 
  5. Johnston SL, Lock RJ, Gompels MM. Takayasu arteritis: a review. J  Clin Pathol. 2002;55(7):481–486. 
  6. Toshihiko N. Current status of large and small vessel vasculitis in  Japan. Int J Cardiol. 1996;54 Suppl:S91–S98. 
  7. Cheung CM, Hegarty J, Kalra PA. Dilemmas in the management of  renal artery stenosis. Br Med Bull. 2005;73–74:35–55. 
  8. Moriwaki R, Noda M, Yajima M, et al. Takayasu arteritis Clinical  manifestations of Takayasu arteritis in India and Japan—new  classification of angiographic findings. Angiology. 1997;48(5):369– 79. 
  9. Arend WP, Michel BA, Bloch DA, Hunder GG, Calabrese LH,  Edworthy SM, et al. The American College of Rheumatology 1990  criteria for the classification of Takayasu arteritis. Arthritis Rheum.  1990;33(8):1129–1134. 
  10. Ishikawa K. Diagnostic approach and proposed criteria for the  clinical diagnosis of Takayasu’s arteriopathy. J Am Coll Cardiol.  1988 Oct;12(4):964-72. 
  11. O’Connor TE, Carpenter HE, Bidari S, Waters MF, Hedna VS. Role  of inflammatory markers in Takayasu arteritis disease monitoring.  BMC Neurol. 2014;14:62. 
  12. Park MC, Lee SW, Park YB, Chung NS, Lee SK. Clinical  characteristics and outcomes of Takayasu’s arteritis: analysis of  108 patients using standardized criteria for diagnosis, activity  assessment, and angiographic classification. Scand J Rheumatol.  2005;34(4):284–292. 
  13. Sharma S, Gupta A. Visceral Artery Interventions in Takayasu’s  Arteritis. Semin Intervent Radiol. 2009;26(3):233–244.
  14. Sharma S, Rajani M, Talwar KK. Angiographic morphology in  nonspecific aortoarteritis (Takayasu’s arteritis): a study of 126 patients  from north India. Cardiovasc Intervent Radiol. 1992;15(3):160–165.
  15. Hotchi M. Pathological studies on Takayasu arteritis. Heart Vessels  Suppl. 1992;7:11–17. 
  16. Nasu T. Pathology of pulseless disease. A systemic study and  critical review of twenty-one autopsy cases reported in Japan.  Angiology. 1963;14:225–242. 
  17. Domingo RT, Maramba TP, Torres LF, Wesolowski SA.  Acquired aorto-arteritis. A worldwide vascular entity. Arch Surg.  1967;95(5):780–790. 
  18. Hauenstein E, Frank H, Bauer JS, Schneider KT, Fischer T.  Takayasu’s arteritis in pregnancy. J Perinat Med. 2010;38(1):55-62.
  19. Pang N, Xie C, Yang M, Feng D, Cheng Y. Clinical efficacy of  percutaneous transluminal renal artery stenting for the treatment of  renovascular hypertension associated with Takayasu arteritis. Ann  Vasc Surg. 2015;29(4):816–821. 
  20. Tyagi S, Singh B, Kaul UA, Sethi KK, Arora R, Khalilullah M. Balloon  angioplasty for renovascular hypertension in Takayasu’s arteritis. Am  Heart J. 1993;125(5 Pt 1):1386–1393. 
  21. Sharma S, Gupta H, Saxena A, et al. Results of renal angioplasty in  nonspecific aortoarteritis (Takayasu disease). J Vasc Interv Radiol.  1998;9(3):429–435. 
  22. Park HS, Do YS, Park KB, et al. Long term results of endovascular  treatment in renal arterial stenosis from Takayasu arteritis: angioplasty  versus stent placement. Eur J Radiol. 2013;82(11):1913–1918.
License

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License, which permits use, share — copy and redistribute the material in any medium or format, adapt — remix, transform, and build upon the material, as long as you give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use. You may not use the material for commercial purposes. If you remix, transform, or build upon the material, you must distribute your contributions under the same license as the original. You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit https://creativecommons.org/licenses/by-nc-sa/4.0/.