Education And Debate

Grand Rounds—Hammersmith Hospital: A physiology classic revisited after 60 years

BMJ 1996; 312 doi: (Published 20 April 1996) Cite this as: BMJ 1996;312:1029

Goldblatt's “one kidney, one clipped” model of renovascular hypertension in a human

Hypertension affects 10-15% of the population. Most cases (over 90%) are essential hypertension. Renovascular causes are the most common cause of secondary hypertension. In the first third of this century, Harry Goldblatt worked on the theory that all cases of raised blood pressure were secondary to renal ischaemia. He produced his classic work on renovascular hypertension in the early 1930s, based on animal experiments. The “one kidney, one clipped” model is unusual in clinical practice. It is compared to hypertension secondary to bilateral renal artery stenosis. We present an unusual sequence of events that recreates the classic model combined with a brief review of the revascularisation options.

Case report

A 47 year old woman presented to the accident and emergency department of this hospital complaining of six weeks of lethargy and a recently discovered large lump in her abdomen. In the past she had had migraine, which was treated with sumatriptan, and untreated labile hypertension. She was a non-smoker who drank alcohol occasionally. She had no relevant family medical history and no significant risk factors for vascular disease.

On examination, she was pale, thin, and afebrile, with a regular pulse of 80 beats/min, blood pressure 110/80 mm Hg, normal heart sounds, and a clear chest. A large mass was found in the left upper abdominal quadrant, which was painless, lobulated, and palpable 4-6 cm below the left costal margin. The rest of the clinical examination was unremarkable.

The investigations included a mild normochromic normocytic anaemia with a haemoglobin concentration of 96 g/l. The urea, creatinine, and electrolyte concentrations were normal. Ultrasound scans and computed tomograms showed a mixed density solid mass measuring 8 cmx9 cmx9 cm arising on the middle and lower thirds of the left kidney and extending anteriorly and inferiorly (fig 1). The patient was given a blood transfusion and …

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