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Hypertensive retinopathy; Choroidopathy; Renal artery stenosis; Hyperhomocystinaemia

Background

Renal artery stenosis is a narrowing of artery that carries blood to kidney (Figure 1) [1]. Renal artery stenosis often leads to secondary hypertension and kidney damage. Hypertensive retinopathy is a common clinical finding among hypertensive patients [2]. Hyperhomocystinaemina leads to renal artery stenosis can be considered as one of the rare cause [3]. However, numerous studies investigated the role of homocysteine as a predictor of vascular diseases most often seen in older people with atherosclerosis [4].

Figure 1: Left renal artery stenosis leading to the kidneys becomes narrowed, preventing adequate blood flow to the kidneys.

Case presentation

A 56 year old male came to our hospital in emergency department with history of blurring of vision in both eyes. He consulted ophthalmologist, where he was diagnosed with bilateral retinal haemorrhages. Blood pressure was found 250/140 millimetres of mercury (mmHg) at time of arrival as well as ST-T segment changes in echocardiogram. Therefore, the patient was admitted to our hospital for further management.

After admission he went through all the investigations. Blood investigations suggested altered lipid profile, significantly increased homocysteine levels, borderline HBA1C levels, significantly elevated urine micro albumin and altered creatinine. On ophthalmology examination patient was found to have retinopathy & choroidopathy. On sonography examination left kidney appeared small in size with grade I increase renal echo-pattern. Right kidney showed compensatory hypertrophy with grade I increase in echo-pattern. On renal color doppler (Figure 2) examination left kidney showed absent arterial flow within main renal arteries, interlobar arteries and intersegmental branches. However, the left renal vein appeared normal and showed normal colour filling. The findings suggested complete left renal artery stenosis. For further confirmation renal angiography was done (Figure 3) and it showed 100% left renal artery stenosis.

Figure 2: Renal color doppler examination showing (a) Normal right renal artery Doppler (b) Left kidney showed absent arterial flow within at main renal arteries, interlobar arteries and intersegmental branches.

Figure 3: (a) Normal right renal angiography (b) Left renal angiography showed 100% left renal artery stenosis.

Conclusion

Hyperhomocystinaemia leads to renal artery stenosis can be considered as one of the rare cause [3]. However, numerous studies investigated the role of homocysteine as a predictor of vascular diseases. A positive association was demonstrated between plasma homocysteine levels and extent of atherosclerosis [3].However, Hypertensive retinopathy and choroidopathy is a common finding among hypertensive patients [2]. Renal artery stenosis (RAS) is the major cause of renovascular hypertension and may account for 1-10% of the 50 million cases of hypertension [4]. Ultrasound and doppler are useful in finding out renal artery disease progress early [5]. Intraarterial digital subtraction angiography is the standard diagnostic test for renal artery stenosis (RAS) [6].

1. Safian RD, Textor SC (2001) . N Engl J Med 344: 431-442.

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2. Wong TY, Mitchell P (2004) . N Engl J Med 351: 2310-2317.

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3. McCully KS (1969) . Am J Pathol 56: 111-128.

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4. Hansen KJ, Edwards MS, Craven TE, Cherr GS, Jackson SA, et al. (2002) . J Vasc Surg 36: 443-451.

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5. Hoffmann U, Edwards JM, Carter S, Goldman ML, Harley JD, et al. (1991) Role of duplex scanning for the detection of atherosclerotic renal artery disease. Kidney Int 39: 1232-1239.

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6. Erley CM, Bader BD, Berger ED, Tuncel N, Winkler S, et al. (2004) . 19: 2526-2531.

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