Rom J Morphol Embryol 2016, 57(2):591–594 ISSN (print) 1220–0522 ISSN (online) 2066–8279 CASE REPORT Renal artery bilateral arteriosclerosis cause of resistant hypertension in hemodialysed patients ANDREI NICULAE 1,2) , ILEANA PERIDE 1,2) , ADRIANA MARINESCU-PANINOPOL 1) , CAMELIA DOINA VRABIE 3,4) , OCTAV GINGHINĂ 5,6) , CRISTIAN RADU JECAN 7,8) , OVIDIU GABRIEL BRATU 2,9) 1) Department of Nephrology and Dialysis, “St. John” Emergency Clinical Hospital, Bucharest, Romania 2) Clinical Department No. 3, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 3) Department of Pathology, “St. John” Emergency Clinical Hospital, Bucharest, Romania 4) Preclinical Department No. 2, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 5) Department of Surgery, “St. John” Emergency Clinical Hospital, Bucharest, Romania 6) Department No. 2, Faculty of Dentistry, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 7) Department of Plastic Surgery and Reconstructive Microsurgery, “Prof. Univ. Dr. Agrippa Ionescu” Emergency Clinical Hospital, Bucharest, Romania 8) Clinical Department No. 11, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 9) Department of Urology, “Dr. Carol Davila” Central Military Emergency University Hospital, Bucharest, Romania Abstract We present the case of a 57-year-old hemodialysed male patient known with severe hypertension resistant to six classes of hypotensive medication, in maximal doses, correlated with increased ultrafiltration during the hemodialysis session. In this case, bilateral nephrectomy was performed as final treatment option for malignant hypertension, and histopathological examination of both kidneys emphasized arteriosclerosis lesions. The results consisted in better hypertension management, with a reduction in both the number and doses of antihypertensive drugs. Keywords: malignant hypertension, hemodialysis, nephrectomy, outcome.  Introduction Malignant arterial hypertension (MHT) is a severe disease that produces retinopathy stage three or four (retinal exudates and hemorrhages ± papilledema), resistant to three or more hypotensive classes of drugs in maximal doses [1, 2]. It is a disease with a high risk of cardio- vascular events (stroke, myocardial infarction) with a higher rate of mortality in the absence of a fast and proper treatment [3–5]. One of the main causes of secondary renal MHT is atherosclerotic renal artery stenosis, especially when the lesions are severe – over 70% obstruction [2, 5, 6]. Between 10–45% of patients with MHT are estimated to have renal artery stenosis [5, 7, 8]. In general, male population over 45-year-old is more affected [5]. The stenosis produces renal hypoperfusion with hyperactiva- tion of rennin–angiotensin–aldosterone system (RAAS), consequently leading to hydrosaline retention with elevated arterial pressure [5, 9]. About 23% of MHT cases are associated with chronic kidney disease (CKD), in which hypertension has a multifactorial pathogenesis: usually is volume dependent, but also hyperstimulation of RAAS, and nervous sympathetic system, nitric oxide deficiency or high level of endothelin and oxidative stress are implicated [5, 10–15]. In general, patients with MHT and CKD must be submitted to investigation for the presence of renal artery stenosis. Duplex ultrasonography, computed tomographic angiography (CTA) and magnetic resonance angiography (MRA) are the most commonly used screening tests; plasma renin activity is no longer used; but arteriography remains the “gold standard” for the diagnosis of renal artery stenosis [5, 16–18]. For the treatment of resistant arterial hypertension is recom- mended to associate up to three or more classes of hypotensive drugs with different action mechanisms (e.g., diuretics) along with controlling the other risk factors [5, 19–22]. When medication is no longer effective, it is necessary to perform revascularization surgery (percuta- neous transluminal angioplasty, stent or by-pass) or trans- catheter renal denervation with radiofrequency of the adventitial renal artery sympathetic nerves [5]. Bilateral nephrectomy is required in case of bilateral stenosis asso- ciated with CKD (with other etiology than ischemia) and repeated episodes of pulmonary edema that are potentially life threatening. The aim of the present case report was to emphasize the need of bilateral nephrectomy on the management of malignant arterial hypertension due to bilateral renal artery stenosis in chronic hemodialysed patients.  Case presentation A 57-year-old male patient known with autosomal dominant polycystic kidney disease and on chronic hemo- dialysis program for four years presented the following symptomatology for three months: intense headache, vertigo, impaired vision and constantly very high values of arterial pressure (systolic blood pressure 280/130 mmHg), resistant to medical treatment and high ultrafiltration. Serum analysis results emphasized creatinine 13.3 mg/dL, R J M E Romanian Journal of Morphology & Embryology http://www.rjme.ro/