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Clinical Review Lesson of the week

Bilateral renovascular disease causing cardiorenal failure

BMJ 2003; 326 doi: (Published 01 March 2003) Cite this as: BMJ 2003;326:489
  1. Alison Brammah, staff grade nephrologist (,
  2. Sue Robertson, staff grade nephrologist,
  3. Graeme Tait, consultant cardiologist,
  4. Chris Isles, consultant physician
  1. Renal Unit and Department of Cardiology, Dumfries and Galloway Royal infirmary, Dumfries DG1 4AP
  1. Correspondence to: A Brammah
  • Accepted 5 September 2002

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.112 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.

Case report

A 75 year old woman with moderate left ventricular systolic dysfunction after an inferior myocardial infarction required temporary haemodialysis when she became moribund with cardiorenal failure while receiving an angiotensin converting enzyme inhibitor. Blood pressure was 102/58 mm Hg, and she had gross pulmonary and peripheral oedema. Her serum creatinine concentration was 731 µmol/l (reference range 70-120 µmol/l). She had had three less severe episodes of cardiorenal failure in the previous 15 months, each associated with an angiotensin converting enzyme inhibitor (fig 1). On ultrasonography the left kidney measured 7.0 cm and the right kidney 9.5 cm. Arteriography showed occlusion of the …

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