Consider renovascular disease in patients with cardiorenal failure

The association between heart failure and bilateral renovascular disease was first recorded in 1988 and has since been the subject of numerous reports.1^–12 Acute or “flash” pulmonary oedema is most commonly described, but chronic heart failure can also occur. Heart failure is thought to arise when the kidneys, “protected” by bilateral stenoses, fail to mount a pressure natriuresis to high arterial pressure. The syndrome is therefore characterised by fluid retention rather than ventricular failure. Clinical clues include the association of cardiac and renal failure with hypertension, widespread vascular disease, inequality of renal size (1.5 cm difference) on ultrasonography, and a reversible increase in serum creatinine concentrations after taking an angiotensin converting enzyme inhibitor.13 A proportion of patients with this clinical syndrome may be cured by renal revascularisation. We report on such a case.