Correspondence

Renal-Artery Stenosis

N Engl J Med 2001; 345:221July 19, 2001

Article

To the Editor:

In their review article on renal-artery stenosis (Feb. 8 issue),1 Safian and Textor indicate that the results of surgery and interventional radiology are better for hypertension associated with fibromuscular hyperplasia than for atherosclerotic renal-artery stenosis.

The explanation for this may lie in the finding by my colleagues and me2,3 that fibromuscular hyperplasia may not cause renal-artery stenosis and that the saccular dilatations reshape the pulse wave to a flat sine wave, without diminishing the perfusion of the kidney.

Stanley B. Reich, M.D.
University of California, Davis, School of Medicine, Sacramento, CA 95817
asreich@worldnet.att.net

3 References

1. 1

   Safian RD, Textor SC. Renal-artery stenosis. N Engl J Med 2001;344:431-442
   Full Text | Web of Science | Medline

2. 2

   Christopher RA, Reich SB, Riley JC, Walker LA. Proceedings: in vitro analysis of wave propagation characteristics of pathological renal arteries. Biomed Sci Instrum 1974;10:71-77
   Medline

3. 3

   Reich SB, Riley JC III, Christopher RA, Walker LA, Everitt JH. Changes in the pulse wave form with flow through vessels with repetitive saccular dilatations and stenosis. Invest Radiol 1975;10:622-626
   CrossRef | Web of Science | Medline

To the Editor:

I read the review article on renal-artery stenosis by Safian and Textor with great expectations, since the topic is of intense familial interest. The article was in the Medical Progress section of the Journal, so I probably shouldn't have been surprised that a review of a topic that a few years ago would have been at least subtitled “Goldblatt hypertension”1 made not a single reference to Harry Goldblatt's pioneering work2 on the subject.

Peter J. Goldblatt, M.D., M.P.H.
Medical College of Ohio, Toledo, OH 43699
pgold67@aol.com

2 References

1. 1

   Goldblatt PJ. The Goldblatt experiment: a conceptual paradigm. In: Laragh JH, Brenner BM, eds. Hypertension: pathophysiology, diagnosis, and management. 2nd ed. Vol. 1. New York: Raven Press, 1995:23-35.
   

2. 2

   Goldblatt H, Lynch J, Hanzal RF, Summerville WW. Studies on experimental hypertension. I. The production of persistent elevation of systolic blood pressure by means of renal ischemia. J Exp Med 1934;59:347-379
   CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: We appreciate Dr. Reich's comments, which offer insight into the mechanism of hypertension associated with fibromuscular disease of the renal artery. However, personal observations with intravascular ultrasonography indicate that multiple weblike defects are often present in patients with fibromuscular dysplasia, contributing to clinically significant stenoses that are frequently inapparent on angiography. Thus, renal ischemia may lead to renovascular hypertension in such patients. These weblike structures can be easily disrupted by balloon inflations, a fact that may partially explain the value of angioplasty in hypertensive patients with fibromuscular dysplasia.

Dr. Goldblatt accurately describes the pioneering work of Harry Goldblatt and his contributions to the understanding of renin-dependent hypertension. In truth, our failure to mention Harry Goldblatt's work in our review has more to do with space limitations than our failure to recognize his enormous contributions.

Robert D. Safian, M.D.
William Beaumont Hospital, Royal Oak, MI 48073
rsafian@beaumont.edu

Stephen Textor, M.D.
Mayo Clinic, Rochester, MN 55905