Renal artery fibromuscular dysplasia: a difficult case to ha
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Renal artery fibromuscular dysplasia (FMD) could be a challenging disease to be diagnosed. Patients with this condition may suffer from symptomatic and resistant hypertension.

Many patients do not have abnormalities on their physical exam or in the routine lab tests. Treatment includes renal artery angioplasty if patient is symptomatic and blood pressure is resistant. The present case has been reported in the European Heart Journal - Case Reports.

A 40-year-old female patient was concerned because despite taking verapamil 160 mg/day, losartan 100 mg/day, and hydrochlorothiazide 25 mg/day her diastolic blood pressure was over 100 mmHg. Routine serum and urine lab tests and a transthoracic echocardiogram were done and were normal.

The treatment was increased over the next consultations but without control of her blood pressure. She developed resistant hypertension, and she was taking four antihypertensive drugs and two diuretics.

A first renal artery Doppler was normal. Because of a high clinical suspicion a renal angio-CT was performed showing bilateral fibromuscular dysplasia. The patient underwent a renal artery angioplasty with balloon with excellent results and better control of her blood pressure after the procedure.

Over the next month, her doctors were able to decrease her treatment to two drugs at intermediate doses. Currently, she is doing well and asymptomatic.

Learning points
• Renal fibromuscular dysplasia (FMD) is an uncommon disease. High clinical suspicion is necessary for making this diagnosis.

• Secondary hypertension and kidney failure due to renal FMD are potentially curable diseases when treated opportunely. Those patients who are not cured through initial treatment may benefit from invasive treatment to improve blood pressure control and renal function.

• The most common and initial imaging method for diagnosing renal FMD is duplex ultrasound (US). Duplex US can show a false negative depending on the operator’s experience, patient’s obesity, or gas interposition. If duplex US is negative and clinical suspicion is still high, then an angio-CT or angio-MR should be done.

• Invasive treatment for symptomatic renal FMD includes renal angioplasty or surgical revascularization.

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