Revisiting the role of nephrectomy for advanced renovascular disease

BACKGROUND: Despite the advances in antihypertensive therapy and renal revascularization, there remains a group of patients in whom renovascular disease leads to renal atrophy and treatment-resistant hypertension. METHODS: We performed an observational cohort study in which we reviewed blood pressures, renal function, and predictors of response in 74 patients who underwent nephrectomy of a small kidney for uncontrolled hypertension between 1990 and 2000. RESULTS: The median age of the patients was 65 years; 43 (58%) were women. Thirty-five patients (47%) underwent nephrectomy as part of combined revascularization of the contralateral kidney. Associated atherosclerotic diseases were common (28% to 49%), as were prior renal revascularization (21 [28%]) and hypertensive urgency/emergencies (23 [31%]). The mean ( SD) long axis of the affected kidney was 8 +/- 2 cm, and the mean function of the kidney (based on radioisotope renography) was 12% +/- 11% of total renal function. The average systolic blood pressure fell from 168 +/- 19 mm Hg to 13.6 +/- 18 mm Hg (P <0.0001) and diastolic blood pressure declined from 88 +/- 10 mm Hg to 76 9 mm Hg (P <0.0001) at the most recent available clinic visit (mean follow-up, 4.1 +/- 2.6 years). In addition, the number of antihypertensive medications decreased from 3.2 +/- 1.1 to 2.2 +/- 1.5 (P <0.0001). Renal function remained stable. Results were similar (preoperative blood pressure of 165/88 mm Hg taking three medications to 137/77 mm Hg taking two medications) among the 39 patients who had a nephrectomy without contralateral revascularization. CONCLUSION: Our results suggest that in selected patients with resistant hypertension and renal artery disease that has resulted in atrophic kidneys with reduced function, nephrectomy can improve blood pressure control without further loss in overall renal function.