Mineralocorticoid Receptor Antagonists for Recurrent Hypertensive Emergency due to Bilateral Renal Artery Stenosis

Introduction: Bilateral renal artery stenosis (RAS) causing recurrent hypertensive emergency and pulmonary oedema is difficult to manage. Use of angiotensin converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARB) is usually contraindicated. We present a systematic review of literature and a case vignette which highlights the useful properties of mineralocorticoid receptor antagonists (MRAs) in this scenario. Methods: Medline, EMBASE, and the Cochrane Central Register of Controlled Trials were searched. Online searches were also conducted. Eligible studies involved the use of MRAs in bilateral RAS. Our search included case reports, case series, case-controls, cohort studies, randomised controlled trials, and systematic reviews. Consensus guidelines on the management of bilateral RAS were also included. Results: 354 abstracts were screened. One case report was included for review. This reported successful use of eplerenone in bilateral RAS following unilateral renal artery stenting. Online search yielded one international guideline for inclusion. This did not mention the use of MRAs in bilateral RAS. Discussion and conclusion: There is no evidence or recommendations from controlled trials, cohort studies, or consensus guidelines to inform clinicians on the use of MRAs in bilateral RAS. One case report describes successful use of eplerenone for management of refractory hypertension secondary to bilateral RAS. We describe our experience of the successful addition of spironolactone to an anti-hypertensive regimen which prevented recurrence of hypertensive emergency and pulmonary oedema in a patient with multiple previous hospital admissions. We feel that MRAs offer an effective and relatively safe but underused option in this condition.