Renal artery embolization for managing uncontrolled hypertension in a kidney transplant candidate
A 34-year-old anuric male with end-stage renal failure (glomerular filtration rate (GFR) <5 mL/min/1.73 m2) secondary to focal segmental glomerulosclerosis presented to the Emergency Department complaining of confusion and restlessness. The patient has a poorly-followed hypertension treated with metoprolol 100 mg bid, amlodipin 5 mg bid, fosinopril 20 mg qd and calcium carbonate 500 tid for 8 years. The patient was on hemodialysis for 7 months prior to admission and he developed malignant hypertension and tonic-clonic seizures after one of the dialysis sessions about 2 month before admission. Consequently, the patient was admitted to the intensive care unit and received intravenous nitroglycerine for 1 week with modifying his medications to: Valsartan 160 mg daily doxazosin 4 mg, fosinopril 10 mg bid. The decision for kidney transplantation was made, but was not possible because of his drug-resistant hypertension.\nAfter a few days, he developed two tonic-clonic seizures, which were treated with diazepam and IV phenytoin. His BP was 230/140 mmHg after these seizures. He received hemodialysis sessions twice a week for 2 months (weight before dialysis: 56 kg, dry weight: 52 kg) until the decision was made to perform RAE. Abdominal multi-slice computed tomography scan prior to performing RAE showed 60% stenosis in the left renal artery and 90% stenosis in the right renal artery [] and renal sizes were 7.3 cm on the right and 8.2 cm on the left.\nRAE was carried out through a right common femoral artery access using the n-butyl-2-cyanoacrylate (Histoacryl; B. Braun, Melsungen, Germany) and lipidol delivered via a 5 Fr Cobra catheter [] with no major periprocedural complications. The patient developed the post-embolization syndrome following the procedure manifested by severe flank pain treated with analgesics.\nAfter performing RAE, the patient's blood pressure declined to 170/100 mmHg, and he was discharged home on amlodipine 5 mg bid, clonidine 150 mcg bid, and nebivolol 5 mg bid. Renal transplantation was performed successfully without complications and he was discharged on amlodipine 5 mg and nabivolol 5 mg qd. 6 month following transplantation, the patient's creatinine was 1 mg/dl and the blood pressure normalized to 120/80 mmHg.