Flash pulmonary edema in renal artery stenosis: Pickering Syndrome

Flash pulmonary edema in renal artery stenosis: Pickering Syndrome

Flash pulmonary edema occurs rapidly and resolves rapidly. The original description was by Pickering et al in 1988 [1]. Hence the entity has been termed Pickering syndrome by Messerli FH et al [2]. It is seen with either bilateral renal artery stenosis or in case of single functional kidney with ipsilateral renal artery stenosis. Occasionally, it has also been reported with unilateral renal artery stenosis and bilateral functioning kidneys [3]. Most episodes of flash pulmonary edema occur at night. Nocturnal dip in blood pressure may have a role in reducing renal perfusion and provoking the flash pulmonary edema [4]. Renin angiotensin aldosterone system has been implicated in the genesis of flash pulmonary edema with renal artery stenosis. Renin release from the juxtaglomerular apparatus can cause intravascular volume expansion due to sodium and water retention. In case of unilateral renal artery stenosis, sodium overload is prevented by natriuresis in the contralateral normal kidney, thus protecting the person from pulmonary edema. This protective mechanism cannot function in the case of bilateral renal artery stenosis or unilateral renal artery stenosis in the single functioning kidney.

Doppler ultrasonography has low sensitivity for detection of renal artery stenosis. CT angiography and magnetic resonance imaging are possible alternatives prior to invasive renal angiography which is needed during definitive treatment like renal angioplasty and stenting. Carbon dioxide angiography, though difficult to perform, may be considered in those with deranged renal function, instead of iodinated contrast angiography which has a potential for contrast nephropathy.

References

1. Pickering TG et al. Recurrent pulmonary oedema in hypertension due to bilateral renal artery stenosis: treatment by angioplasty or surgical intervention. Lancet. 1988; 2: 551–552.
2. Messerli FH et al. Flash pulmonary oedema and bilateral renal artery stenosis: the Pickering Syndrome. Eur Heart J. 2011 Sep;32(18):2231-5.
3. Hye Jin Noh et al. Flash Pulmonary Edema in a Patient With Unilateral Renal Artery Stenosis and Bilateral Functioning Kidneys. Hye Jin Noh Korean Circ J. 2010 January; 40(1): 42–45.
4. Mansoor S et al. ‘Flash pulmonary oedema’- a diagnosis for both the cardiologist and the nephrologist? Nephrol. Dial. Transplant. 2001; 16: 1311-1313.