LOCATION: Outpatient, Clinic PATIENT: Julia Jones PHYSICIAN: George Orbitz, M.D. CHIEF COMPLAINT: Renal artery stenosis. I had a lengthy discussion with this long-time patient, her male friend and her daughter, who is her power of attorney, about the progression of her kidney disease, edema, CHF and her RT renal artery re-stenosis. I have discussed with them in detail the pathology and pathophysiology of renal artery stenosis and its effect on renal function, LV function and HTN. I have discussed also in detail the procedure of renal angiography and its possible complications including acute renal failure from contrast nephropathy that may require either temporary or permanent dialysis. Julia has significant right renal artery re-stenosis on renal arterial doppler with possible progression of her left renal artery stenosis. We discussed also the possibility of renal artery rupture and bleeding complications. Julia and her friends had many questions, all of them were very appropriate questions and all of those questions were answered. We spent quite a bit of time discussing dialysis both hemodialysis and peritoneal dialysis. I have asked the patient and her family to keep their minds open about dialysis. She had bypass surgery already and other than having a CVA, there is no contraindication for dialysis at this time, if she ever needs it. Of course I discussed with them in details IV hydration and minimal contrast in an attempt to avoid contrast nephropathy. I have indicated that I would NEVER recommend that she gets renal artery bypass and she is better off with interventional radiology. We discussed expectations after the procedure and the possibility of re-stenosis again in the future. They understand that there is no guarantee that her RT renal artery will remain open but we will watch it with renal arterial Dopplers at 6 weeks and 3 months after the procedure. In addition to all of the above, I have indicated the objectives of performing renal angiography which are to preserve and hopefully improve her renal function first and improve her BP control second. Unfortunately, she is drinking a lot of water to help her kidney function, despite our discussions about this in the past. I have strongly advised to limit her fluid intake to 1.5 L a day, avoid salty food and increase her Bumex to 2 mg PO BID to help with her edema and exertional dyspnea. She has gained 5-lbs with her weight today at 154-lbs with BP of 178/60 and HR of 76/min. Her lung were clear and she had regular rate and rhythm, but she had neck vein distention and 2+ edema. After the above discussion, patient agreed to proceed with renal angiography next Tuesday (Today is Friday). All those present, including the patient were very satisfied with the visit and the discussion today. They seem to understand all the aspects of renal artery stenosis, chronic renal failure, and CHF, hypertension and the potential benefits and complications of renal angi