Renovascular Hypertension


Renovascular hypertension (RVH) in children if untreated leads to ischemic nephropathy, chronic kidney disease, myocardial infarction, stroke and encephalopathy. RVH is defined as high blood pressure which results from a lesion reducing blood flow to part or all of one or both of the kidneys associated with alteration in the renin-angiotensin mechanism. Incidental hypertension in an asymptomatic child is the most common presentation of RVH. Younger children are more likely to have neurological sequelae like seizures, left ventricular hypertrophy, congestive heart failure, lethargy or poor growth. The most common cause of RVH in children is renal artery stenosis caused by fibromuscular hyperplasia (FMH) and Takayasu arteritis. Syndromes such as Neurofibromatosis, Williams, tuberous sclerosis and vasculitis comprised other less common causes of RVH. FMH is a non-atherosclerotic, non-inflammatory idiopathic angiopathy affecting medium-size arteries. Mid-aortic syndrome is another etiology of RVH referring to localized narrowing of the distal thoracic  or abdominal aorta involving the renal vessels as well. Diagnosis of RVH includes Doppler ultrasound, CT-angiography Scan and MRI, though digital substraction angiography is the gold standard. More than 50% of RVH arterial lesions are bilateral. Management of RVH entails medical, surgical or endovascular options. Medical management only has the least opportunity of cure. Surgical management includes revascularization, bypass or nephrectomy. Endovascular options developed in the adult population are increasing use in children. This endovascular options include mainly percutaneous balloon angioplasty. The use of stents is reserved for severe or recurrent stenosis or management of complications. Open surgical intervention has a higher rate of cure higher than 70%. Angioplasty is often utilized for short arterial narrowing while open surgery is used for long diffuse arterial narrowing or complete occlusion of renal arteries. Residual hypertension is found in one-third of the children managed surgically or percutaneously. Other postop morbidity includes aortic rupture, dissection, bleeding, thrombosis and graft stenosis. Management should be individualized.    

References:
1- Lobeck IN, Alhajjat AM, Dupree P, et al: The management of pediatric renovascular hypertension: a single center experience and review of the literature. J Pediatr Surg. 53: 1825-1831, 2018
2- Lee Y, Lim YS, Lee ST, Cho H: Pediatric renovascular hypertension: Treatment outcome according to underlying disease. Pediatr Int. 60(3):264-269, 2018
3- Alexander A, Richmond L, Geary D, Salle JL, Amaral J, Connolly B: Outcomes of percutaneous transluminal angioplasty for pediatric renovascular hypertension. J Pediatr Surg. 52(3):395-399, 2017
4- Chung H, Lee JH, Park E, et al: Long-Term Outcomes of Pediatric Renovascular Hypertension. Kidney Blood Press Res. 42(3):617-627, 2017
5- Humbert J, Roussey-Kesler G, Guerin P, et al: Diagnostic and medical strategy for renovascular hypertension: report from a monocentric pediatric cohort. Eur J Pediatr. 174(1):23-32, 2015
6- Sandmann W, Dueppers P, Pourhassan S, et al: Early and long-term results after reconstructive surgery in 42 children and two young adults with renovascular hypertension due to fibromuscular dysplasia and middle aortic syndrome. Eur J Vasc Endovasc Surg. 47(5):509-16, 2014


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