Koomans H, Beutler J, van de Ven P, Mali W
Detection of severe bilateral renovascular disease by ACE-
induced renal dysfunction
12th Annual ASH Meeting
Am J Hypertens
(Apr) 10:217A 1997
The authors review the knotty problem of detection of functionally
significant bilateral
renovascular disease (RVD). They report their experience with 108 patients
at risk for
bilateral RVD who they treated for 2 weeks with ACEI with or without
diuretics. They
report that using a criterion of a rise of 320% in plasma creatinine, 100% of
the 52
patients with severe RVD were detected.
Comment: This report continues a proud tradition of searching for the
perfect test
for diagnosing renovascular hypertension. The authors are to be
congratulated for taking
on what is undoubtedly the toughest test situation, bilateral RVD. The
report does not
comment on patient selection or test specificity, so it is difficult to know
how to
interpret a 100% sensitivity. As a trivial example, one can get 100%
sensitivity by
shining a flashlight through hypertensive patients' backs and diagnosing all
subjects in
whom one can't see the light as renovascular disease. Such a test will
certainly detect
all cases of renovascular hypertension (since it will call all hypertensives
renovascular), but specificity will be low and in patient sampled selected
for testing by
clinical crieteria, predictive power will likely be poor. Most early reports
of tests for
renovascular hypertension look promising, and most fall to ruin on the rock
of
specificity. Searching for a needle in a haystack still isn't easy.
The other concern one might have about the approach advocated by the authors
concerns
liability. While it may be that renal failure is a rare event (the present
series does
not include any subjects who went
into renal failure), in the U.S., provocation of irreversible renal
failure would probably be actionable. I doubt very many practitioners
would see the ACE-induced renal dysfunction protocol suggested here as
safe enough for office practice. (Alan Weder, M.D., University of
Michigan)
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12th Annual ASH Meeting
H: Special problems :
Renovascular hypertension