Renal Artery Dilatation in a Patient on Captopril: Changing a ‘Two-Kidney, Two-Clip Hypertension’ into a ‘Two-Kidney, One-Clip Hypertension’

Abstract

In this paper we report on a patient with accelerated hypertension associated with a totally obstructed right renal artery and a severe constricted left one. In this ‘two-kidney, two-clip’ model of renovascular hypertension, captopril in combination with severe sodium restriction was not effective, possibly as a consequence of overloading with sodium and water due to a low renal perfusion pressure at the left side. Transluminal renal artery dilatation changed this ‘two-kidney, two-clip’ into a ‘two-kidney, one-clip’ model of renovascular hypertension, which subsequently responded well to captopril treatment. Some pathophysiological mechanisms involved are briefly discussed.

Captopril-Induced Acute Reversible Renal Failure

“…A similar coincidence between captopril administration and a fall in glomerular filtration rate has been reported in 8 other patients [Gavras et al, 1978;Farrow and Wilkinson, 1979;Collste et al, 1979;Woodhouse et al, 1979;Planz and Bundschu, 1980;Luderer et al, 1981;Hoorntje et al, 1982]. In 4 of these an immunoallergic mechanism was suggested by the presence of fever or skin rash, and in 1 patient patchy atrophy and inflammation were docu mented by renal biopsy .…”

“…It might reflect inhibition of vaso dilating prostaglandin, a mechanism invoked to account for NSAI-induced renal failure [Dunn and Zambraski, 1980], Alternatively, it might result, at least in part, from a decreased filtration fraction due to the inhibition of the vasoconstrictive effect of angiotension on the efferent arter ies. Such a phenomenon has been documented in hyperten sive subjects [Mimraneta\., 1979;Prins, 1979], and in 1 case captopril induced renal failure [Hoorntje et al, 1982], It is noteworthy that our 5 patients suffered from severe bilateral (or unilateral in the case of a single kidney) renal vascular disease. This was also the case in at least 4 of the reported cases of captopril-induced renal failure Collste et al, 1979;Planz and Bundschu, 1980;Hoorntje et al, 1982], This high incidence suggests that patients with severe renal artery disease are prone to the development of captopril-induced renal fail ure.…”

“…Such a phenomenon has been documented in hyperten sive subjects [Mimraneta\., 1979;Prins, 1979], and in 1 case captopril induced renal failure [Hoorntje et al, 1982], It is noteworthy that our 5 patients suffered from severe bilateral (or unilateral in the case of a single kidney) renal vascular disease. This was also the case in at least 4 of the reported cases of captopril-induced renal failure Collste et al, 1979;Planz and Bundschu, 1980;Hoorntje et al, 1982], This high incidence suggests that patients with severe renal artery disease are prone to the development of captopril-induced renal fail ure. In these patients captopril should be used cautiously.…”

Effect of Captopril on Blood Pressure and Renal Function in Patients with Transplant Renal Artery Stenosis

“…Comparable observations have been made by Dzauet al [4] in patients with bilateral renal artery steno sis and Textor et al [13] in patients with a renal artery stenosis in a solitary kidney. We succeeded in abolishing captopril resistance in a patient with renovascular hyper tension by changing a 'two-kidney, two clip hyperten sion' into a 'two-kidney, one clip hypertension' using percutaneous renal artery dilation [8].…”