Tuesday, July 22, 2014

Historical Contribution: 1938, Leadbetter & Burkland, Hypertension in Unilateral Renal Disease


WF Leadbetter, CE Burkland. Hypertension in unilateral renal disease.  - The Journal of Urology, 1938; 39:5, 611-26.

In the 1930's, it was well-established that bilateral renal disease - either obstructive or vascular - could lead to hypertension.  These findings were understood both in laboratory models and corroborated with clinical findings in patients with obstruction due to benign prostatic hyperplasia, vascular nephritis, polycystic kidney disease and polyarteritis nodosa.  In laboratory experiments, scientists were able to induce hypertension with unilateral renal injuries due to a variety of mechanisms: direct surgical destruction of a kidney, ligation of unilateral renal vessels, radiation damage to a kidney and ligation of the ureter to name a few.  However, a consistent clinical correlation was lacking.

Therefore, Drs. Leadbetter and Burkland present a case in which unilateral renal disease resulted in hypertension, and the hypertension resolved with removal of the diseased kidney.  The patient was 5 year-old boy with an ectopic, pelvic kidney and hypertension (consistently 150-170 systolic and 70 diastolic) for a number of years.  Following nephrectomy, the patients blood pressure decreased to normal and persisted there throughout follow-up.

This manuscript is:
1) a wonderful anatomic description of a pelvic kidney
At this point the ectopic kidney could be readily palpated lying over the promontory of the sacrum between the iliac vessels just below the bifurcation of the aorta.  It was necessary to bluntly incise a connective tissue layer, which corresponded to Gerota's fascia, before the anterior surface of the kidney could be exposed...Study of the kidney in situ showed that the artery and vein came from above to enter the hilum of the kidney just above the pelvis, lay in a deep grove on the anterior surface of the kidney, and were under considerable tension.  The renal artery appeared unusually small.

2) correlation between meticulous clinical measurements,observation and anatomy/pathology to arrive at a hypothesis of pathophysiology

The surface [of the kidney] showed great irregularity with numerous grooves and depressionswhich corresponded to its relationship with the renal artery and vein, the right iliac artery, and the surface of the sacrum...The renal artery was of small caliber and several cross sections showed at a point about 1cm. from the hilum of the kidney partial occlusion.
Interestingly, there was no evidence of inflammatory or infectious disease and the glomeruli were normal in appearance.

3) important evidence and hypothesis for unilateral disease causing hypertension.  

The authors hypothesized that "renal ischemia" produces nervous impulses that reflexly cause a rise in blood pressure.  Part of this was believed to be a compensatory phenomenon to preserve renal blood flow in a condition of compromised flow.  Possibly, the kidney secretes a hormone or substance in response to impaired local circulation that exercises a pressor action.  Today we know that all three of these mechanisms exist in renovascular hypertension.

To read the entire manuscript click on the link above or here.

HISTORICAL CONTRIBUTIONS highlight the greatest academic manuscripts from the Brady Urological Institute over the past 100 years.  As the Brady Urological Institute approaches its centennial, we will present a HISTORICAL CONTRIBUTION from each of the past 100 years.  In the most recent experience, the most highly cited article from each year is selected; older manuscripts were selected based on their perceived impact on the field.  We hope you enjoy! 


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