Spontaneously Resolving Hyperreninemic Hypertension Caused by Accessory Renal Artery Stenosis in a 13‐Year‐Old Girl: A Case Report

Abstract

The authors describe the clinical investigation and progress of a 13-year-old girl diagnosed with hypertension 4 years prior to her admission. A thorough history was taken and physical examination performed. Laboratory analysis and relevant radiological evaluation were obtained in order to determine the etiology for suspected secondary hypertension, and later to differentiate between the possible causes of hyperreninemic hypertension. The patient had an accessory left renal artery, presumptively leading to renin secretion by the underperfused kidney. The patient was treated medically with spontaneous resolution of her hypertension and near normalization of plasma renin activity. On repeat imaging, the artery was not demonstrated. The authors concluded that the diagnosis of hyperreninemic hypertension in young ages should prompt investigation for the etiology. However, cautious observation is a valid option that might lead to spontaneous resolution. J Clin Hypertens (Greenwich). 2017;19:100-102. Published 2016. This article is a U.S. Government work and is in the public domain in the USA CASE REPORTWe describe a 13-year-old girl diagnosed with hypertension. The patient complained of severe headaches since the age of 7 years. After 2 years, a diagnosis of hypertension, with blood pressure (BP) values up to 170/90 mm Hg (height-and age-adjusted 95th percentile 119/79 mm Hg), was determined. Her parents had no relevant medical history, whereas the mother's sister (aged 37 years) experienced migraines. In addition, both the paternal grandmother and great-grandmother had hypertension presenting during adulthood (>60 years). In light of the high BP values, target organs had been evaluated, including fundoscopy that revealed a mild bilateral hypertensive retinopathy and echocardiography that demonstrated changes secondary to systemic hypertension with preserved left ventricular function. Treatment with amlodipine was initiated and later replaced with enalapril, achieving normal BP values.During her initial evaluation in the community, the patient underwent investigation for secondary hypertension etiologies. This included kidney and renal arteries ultrasonography with Doppler, 24-hour urinary collection for vanilmandelic acid, and thyroid function tests, which were all within reference ranges. In contrast, both plasma aldosterone (PA) levels (89.4 ng/ mL; reference range, 1.5-50) and plasma renin activity (PRA; 13.9 ng/mL/h; reference range, 0.1-2.8) were elevated, as was chromogranin A plasma level (152 ng/ mL; reference range, 31-94). Thus, the workup focused on finding the etiology for excessive renin production, and included angiographic computerized tomography (CT) of the renal arteries, which was interpreted as a narrowing of the left renal vein. The patient was then referred for evaluation at the National Institutes of Health (NIH) clinical center for further evaluation.The patient first admitted to the NIH Clinical Center complaining of fatigue and headaches. Her BP was 106/ 54 mm Hg (between 50th and 90th perce...

Accessory Renal Artery Stenosis and Secondary Hypertension

“…Akbeyaz et al describe a case of a 13-year-old female with hypertension secondary to stenosis of an accessory renal artery identified on renal ultrasound and confirmed on CT angiography [ 7 ]. The patient received antihypertensive pharmacologic treatment and blood pressure goal was achieved [ 7 ].…”

“…At routine follow-up two months later, it was discovered that the patient's blood pressure was much lower than previous measurements and antihypertensive treatment was gradually tapered and discontinued [7]. Repeat renal ultrasound was performed and the accessory artery could no longer be visualized [7]. Spontaneous collapse of the vessel was suspected [7].…”

“…Case Reports in Nephrology renal artery identified on renal ultrasound and confirmed on CT angiography [7]. e patient received antihypertensive pharmacologic treatment and blood pressure goal was achieved [7].…”

Possible interesting link between Janus kinase 2 mutation and renovascular hypertension

“…Also, several cases of renovascular hypertension and renal artery stenosis in MPNs patients have been described . However, in spite of recent progress in the diagnosis and treatment strategy of renovascular hypertension and renal artery stenosis, the common clinical manifestations of patients with MPN‐associated renovascular hypertension are unclear and optimal treatment strategy for the renovascular lesion in such patients are undetermined.…”

“…[5][6][7][8][9][10] Also, several cases of renovascular hypertension and renal artery stenosis in MPNs patients have been described. [11][12][13][14][15][16] However, in spite of recent progress in the diagnosis and treatment strategy of renovascular hypertension and renal artery stenosis, [17][18][19] the common clinical manifestations of patients with MPN-associated renovascular hypertension are unclear and optimal treatment strategy for the renovascular lesion in such patients are undetermined. the authors showed that the stenotic lesions in the renal arteries were radiographically considered to be thrombotic plaque or intimal hyperplasia, which would be associated with PV and ET.…”