The Case: An unusual cause of renovascular hypertension.

A 48-year-old obese male (body mass index, 33), who was an active smoker, was admitted to our department to undergo percutaneous angioplasty of a markedly stenosed left renal artery. Six months earlier, severe hypertension (blood pressure, 200/100 mm Hg) associated with hypokalemia of renal origin (serum potassium level, 3.1 mmol/l; urinary potassium, 75 mmol/day) and stage III chronic kidney disease (serum creatinine level, 146 mmol/l; estimated glomerular filtration rate, 48 ml/min per 1.73 m) were discovered. Doppler ultrasound showed 90% stenosis of the ostium and the first segment of the left renal artery. The right renal artery was normal. Both kidneys were 100 mm in length. Magnetic resonance angiography confirmed the Doppler results and the decision to perform a percutaneous renal angioplasty was made. On admission, the patient’s blood pressure was 135/ 75 mm Hg on three medications including nebivolol (5 mg/ day), amlodipine (5 mg/day), and spironolactone (50 mg/ day). Physical examination was unremarkable. Laboratory findings were as follows: hypertriglyceridemia at 7.5 mmol/l, hypercholesterolemia (HDL cholesterol at 0.61 mmol/l and LDL cholesterol level at 4.97 mmol/l), serum potassium at 3.5 mmol/l, and serum creatinine at 147 mmol/l. Urine analysis was normal. A renal angiography was performed (Figure 1). An unusual finding led us to perform a computed tomography scan angiography (Figure 2).