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Abstract

Despite advances in pharmacological, percutaneous, and surgical treatments of renovascular hypertension, some patients develop refractory hypertension and an atrophic nonfunctioning kidney. The modern role for removal of such kidneys is not clear.

We studied the effect of nephrectomy on long-term BP control, and the predictive value of renal vein renins in 35 patients undergoing nephrectomy at the Mayo Clinic in 1995-1999. All patients had an atrophic kidney due to renal artery disease in the setting of refractory hypertension, i.e. a mean blood pressure of 166/85 despite an average of 3 medications.

The mean age was 61.9 years (27-80) and 28 patients had renal artery atherosclerosis, eight fibro muscular dysplasia, and one Takayasu's arteritis. In our series 24 (68.6%) patients had a clinical benefit from surgery, of whom three (8.6%) were cured of hypertension. By preoperative imaging, the average size of the resected kidney was 7.6cm compared to the contralateral kidney at 11.3cm (n=27) with an average function on renal scan of 5% (n=8). Nephrectomy led to a fall in arterial blood pressure and number of antihypertensive medications following surgery. These reductions persisted at the most recent available clinic follow up (mean of two years) and were not at the expense of renal function. (See Table)

PreoperativeLast follow upp value
sBP166.4 ± 17.7142.6 ± 19.9< 0.0001
dBP84.7 ± 11.278.0 ± 11.8< 0.04
MAP111.9 ± 10.299.9 ± 12.6< 0.0003
# of medications2.9 ± 1.32.2 ± 1.5< 0.006
Calc. GFR51 ± 22.647.5 ± 23.3NS
PreoperativeLast follow upp value
sBP166.4 ± 17.7142.6 ± 19.9< 0.0001
dBP84.7 ± 11.278.0 ± 11.8< 0.04
MAP111.9 ± 10.299.9 ± 12.6< 0.0003
# of medications2.9 ± 1.32.2 ± 1.5< 0.006
Calc. GFR51 ± 22.647.5 ± 23.3NS
PreoperativeLast follow upp value
sBP166.4 ± 17.7142.6 ± 19.9< 0.0001
dBP84.7 ± 11.278.0 ± 11.8< 0.04
MAP111.9 ± 10.299.9 ± 12.6< 0.0003
# of medications2.9 ± 1.32.2 ± 1.5< 0.006
Calc. GFR51 ± 22.647.5 ± 23.3NS
PreoperativeLast follow upp value
sBP166.4 ± 17.7142.6 ± 19.9< 0.0001
dBP84.7 ± 11.278.0 ± 11.8< 0.04
MAP111.9 ± 10.299.9 ± 12.6< 0.0003
# of medications2.9 ± 1.32.2 ± 1.5< 0.006
Calc. GFR51 ± 22.647.5 ± 23.3NS

Twenty patients had preoperative renal vein renin studies. The change in blood pressure after nephrectomy correlated (p=0.04) with the ratio of the renin levels of the affected to unaffected sides. A benefit from nephrectomy was evident above a ratio of 3.

These results indicate that, despite current therapy, nephrectomy for patients with a “pressor kidney” not amenable to revascularisation, successfully aids in blood pressure control and on occasion leads to cure. Renal vein sampling, despite often absent renal artery blood flow, can assist preoperative patient selection.

nephrectomy
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© American Journal of Hypertension, Ltd. 2001
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