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A Rare Cause of Resistant Hypertension: Idiopathic Retroperitoneal Fibrosis

Keywords: idiopathic retroperitoneal fibrosis, resistant hypertension.


AUTHORS:
Burak ACAR, M.D.1
Cengiz Burak, M.D.1
Esra Gucuk Ipek, M.D.2
R1za Sarper Okten, M.D.3 #
Umit Guray, M.D. 4 #
Yesim Guray, M.D.1 #

1.Department of Cardiology, Yuksek Ihtisas Heart-Education and Research Hospital, Ankara/TURKEY
2. Department of Cardiology, Polatli State Hospital, Ankara/TURKEY
3.Department of Radiology, Yuksek Ihtisas Heart-Education and Research Hospital, Ankara/TURKEY
4. Department of Cardiology, Numune Education and Research Hospital, Ankara/ TURKEY

#Assoc. Prof.

Corressponding Author: Dr. Burak Acar
Address: Turkey Yuksek Ihtisas Hastanesi
Kardiyoloji B�l�m� 
06100 S1hhiye / Ankara TURKEY
Tel: +903123061828
Fax: +903123243983
e-mail: burakacarmd@yahoo.com

A Rare Cause of Resistant Hypertension: Idiopathic Retroperitoneal Fibrosis

Abstract

A 48 year-old lady presented with resistant hypertension and impaired renal function. Detailed evaluation with laboratory analyses and imaging modalities led the diagnosis of retroperitoneal fibrosis with a consequent hydronephrosis. Following one-month treatment with the combination of steroid therapy and nephrostomy catheter insertion, fibrous tissue was regressed and the patient�s blood pressure was under control without further complication. 

Keywords: idiopathic retroperitoneal fibrosis, resistant hypertension.

Introduction 

Idiopathic retroperitoneal fibrosis (IRF) is a rare cause of hypertension. Underlying mechanism of hypertension in these patients may be chronic periaortitis as well as the compression of fibrous tissue to renovascular structures. In this case, we report a patient with resistant hypertension, who eventually diagnosed with IRF. 

Case Report

A 48-year-old lady admitted to our outpatient clinic with the complaints of uncontrolled hypertension and lower back pain that had started 3 months earlier. Her medical history was unremarkable apart from a family history of cardiovascular disease. On admission, blood pressure was 180/100 mmHg despite triple antihypertensive treatment with angiotensin converting enzyme inhibitor, calcium channel blocker and diuretic. Left ventricular strain pattern was detected on electrocardiogram; left ventricular hypertrophy, dilated ascending aorta (4.3 cm) and diastolic dysfunction were detected on echocardiogram. Creatinine (1.8 mg/dL), urea nitrogen (63 mg/dL), erythrocyte sedimentation rate (64 mm/h), C-reactive protein (19.4 mg/L) levels were elevated and there was gross hematuria on urine analysis. Renal ultrasonography revealed bilateral dilated renal pelvis and disturbed structure of proximal ureters. On tomography, aorta was calcified and thickened, surrounded with soft tissue starting from infrarenal level to internal iliac artery level. There was distention of the ureters, renal pelvis and calices; with accompanying right sided grade 3 hydronephrosis (Figure 1). The findings suggested the diagnosis of retroperitoneal fibrosis. Hydronephrosis was treated with nephrostomy catheter insertion and steroid therapy was initiated. After one-month therapy, magnetic resonance imaging showed resolution of fibrous tissue around the aorta (Figure 2). The patient�s hypertension was under control with only one drug; inflammatory markers and renal function tests regressed to normal range. The patient did not need further antihypertensive drug three months after the therapy.

Discussion

Retroperitoneal fibrosis is a rare disease of retroperitoneum characterized by increased fibrosclerotic tissue leading to compression of the surrounding structures  ADDIN EN.CITE  ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_1" \o "Pipitone, 2012 #864" 1). When there is no secondary cause (i.e. drugs, tumors or infections) it is classified as idiopatic ADDIN EN.CITE  ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_1" \o "Pipitone, 2012 #864" 1). IRF incidence is higher in male patients and mean presentation time is 50th and 60th decade  ADDIN EN.CITE <EndNote><Cite><Author>Baker</Author><Year>1987</Year><RecNum>11</RecNum><DisplayText>(2)</DisplayText><record><rec-number>11</rec-number><foreign-keys><key app="EN" db-id="vwzwt25r7f0szmed50dxpxfl0zavfdr5e5rv">11</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Baker, L. R.</author><author>Mallinson, W. J.</author><author>Gregory, M. C.</author><author>Menzies, E. A.</author><author>Cattell, W. R.</author><author>Whitfield, H. N.</author><author>Hendry, W. F.</author><author>Wickham, J. E.</author><author>Joekes, A. M.</author></authors></contributors><auth-address>Department of Nephrology, St Bartholomew&apos;s Hospital, London.</auth-address><titles><title>Idiopathic retroperitoneal fibrosis. A retrospective analysis of 60 cases</title><secondary-title>Br J Urol</secondary-title></titles><periodical><full-title>Br J Urol</full-title></periodical><pages>497-503</pages><volume>60</volume><number>6</number><edition>1987/12/01</edition><keywords><keyword>Adrenal Cortex Hormones/therapeutic use</keyword><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Combined Modality Therapy</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Retroperitoneal Fibrosis/*diagnosis/mortality/therapy</keyword><keyword>Retrospective Studies</keyword><keyword>Ureter/surgery</keyword></keywords><dates><year>1987</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>0007-1331 (Print)&#xD;0007-1331 (Linking)</isbn><accession-num>3427331</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/3427331</url></related-urls></urls><language>eng</language></record></Cite></EndNote>( HYPERLINK \l "_ENREF_2" \o "Baker, 1987 #11" 2) . Although etiology for IRF is unknown, Sakamoto el al. reported that % 76 of the patients with retroperitoneal fibrosis had smoking history  ADDIN EN.CITE  ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_3" \o "Sakamoto, 2012 #868" 3). Recently, it has been suggested that IRF is a component of chronic periaortitis which was previously considered as a type of atherosclerosis of the aorta (1)..Today, it is known that chronic periaortitis is a systemic immune-mediated disease and related with immunoglobulin-G4 (IgG4) deposition  ADDIN EN.CITE <EndNote><Cite><Author>Park</Author><Year>2012</Year><RecNum>891</RecNum><DisplayText>(4)</DisplayText><record><rec-number>891</rec-number><foreign-keys><key app="EN" db-id="er05av0rndstrmeas51x5wfa0sa5evsv0p0s">891</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Park, S. H.</author><author>Im, C. H.</author><author>Yang, D. H.</author><author>Kang, J. W.</author><author>Yoon, J. Y.</author><author>Cho, H. J.</author><author>Park, H. S.</author><author>Cho, Y.</author><author>Chae, S. C.</author><author>Jun, J. E.</author></authors></contributors><auth-address>Department of Cardiology, Kyungpook National University Hospital, Daegu, Korea.</auth-address><titles><title>A case of chronic periaortitis with retroperitoneal fibrosis</title><secondary-title>Korean Circ J</secondary-title><alt-title>Korean circulation journal</alt-title></titles><periodical><full-title>Korean Circ J</full-title><abbr-1>Korean circulation journal</abbr-1></periodical><alt-periodical><full-title>Korean Circ J</full-title><abbr-1>Korean circulation journal</abbr-1></alt-periodical><pages>857-60</pages><volume>42</volume><number>12</number><dates><year>2012</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>1738-5520 (Print)&#xD;1738-5520 (Linking)</isbn><accession-num>23323126</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/23323126</url></related-urls></urls><custom2>3539054</custom2><electronic-resource-num>10.4070/kcj.2012.42.12.857</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_4" \o "Park, 2012 #891" 4). 
Clinical presentation of IRF is related to mechanical compression of fibrotic retroperitoneal tissue to the adjacent structures causing a broad spectrum of symptoms such as back pain, abdominal pain, ureteral colic, deep vein thrombosis, claudication and testicular pain  ADDIN EN.CITE <EndNote><Cite><Author>Park</Author><Year>2012</Year><RecNum>891</RecNum><DisplayText>(4)</DisplayText><record><rec-number>891</rec-number><foreign-keys><key app="EN" db-id="er05av0rndstrmeas51x5wfa0sa5evsv0p0s">891</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Park, S. H.</author><author>Im, C. H.</author><author>Yang, D. H.</author><author>Kang, J. W.</author><author>Yoon, J. Y.</author><author>Cho, H. J.</author><author>Park, H. S.</author><author>Cho, Y.</author><author>Chae, S. C.</author><author>Jun, J. E.</author></authors></contributors><auth-address>Department of Cardiology, Kyungpook National University Hospital, Daegu, Korea.</auth-address><titles><title>A case of chronic periaortitis with retroperitoneal fibrosis</title><secondary-title>Korean Circ J</secondary-title><alt-title>Korean circulation journal</alt-title></titles><periodical><full-title>Korean Circ J</full-title><abbr-1>Korean circulation journal</abbr-1></periodical><alt-periodical><full-title>Korean Circ J</full-title><abbr-1>Korean circulation journal</abbr-1></alt-periodical><pages>857-60</pages><volume>42</volume><number>12</number><dates><year>2012</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>1738-5520 (Print)&#xD;1738-5520 (Linking)</isbn><accession-num>23323126</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/23323126</url></related-urls></urls><custom2>3539054</custom2><electronic-resource-num>10.4070/kcj.2012.42.12.857</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_4" \o "Park, 2012 #891" 4). Hydronephrosis and compression of renal vessels can cause activation of renin-angiotensin-aldosterone system and hypertension. Ureteric obstruction has an insidious course and often leads to asymptomatic hydronephrosis and renal impairment  ADDIN EN.CITE <EndNote><Cite><Author>Acosta</Author><Year>2001</Year><RecNum>905</RecNum><DisplayText>(5)</DisplayText><record><rec-number>905</rec-number><foreign-keys><key app="EN" db-id="er05av0rndstrmeas51x5wfa0sa5evsv0p0s">905</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Acosta, S.</author><author>Leandersson, U.</author><author>Svensson, S. E.</author><author>Johnsen, J.</author></authors></contributors><auth-address>Kirurgiska kliniken, Blekingesjukhuset, Karlskrona.</auth-address><titles><title>[A case report. Endometriosis caused colonic ileus, ureteral obstruction and hypertension]</title><secondary-title>Lakartidningen</secondary-title><alt-title>Lakartidningen</alt-title></titles><periodical><full-title>Lakartidningen</full-title><abbr-1>Lakartidningen</abbr-1></periodical><alt-periodical><full-title>Lakartidningen</full-title><abbr-1>Lakartidningen</abbr-1></alt-periodical><pages>2208-12</pages><volume>98</volume><number>18</number><keywords><keyword>Colonic Diseases/*etiology/radiography</keyword><keyword>Diagnosis, Differential</keyword><keyword>Endometriosis/*complications/radiography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Hypertension/diagnosis/*etiology</keyword><keyword>Intestinal Obstruction/*etiology/radiography</keyword><keyword>Middle Aged</keyword><keyword>Ureteral Obstruction/*etiology/radiography</keyword></keywords><dates><year>2001</year><pub-dates><date>May 2</date></pub-dates></dates><orig-pub>Fallbeskrivning. Endometrios orsakade kolonileus, uretarobstruktion och hypertoni.</orig-pub><isbn>0023-7205 (Print)&#xD;0023-7205 (Linking)</isbn><accession-num>11402601</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/11402601</url></related-urls></urls></record></Cite></EndNote>( HYPERLINK \l "_ENREF_5" \o "Acosta, 2001 #905" 5).
IRF is a diagnosis of exclusion  ADDIN EN.CITE <EndNote><Cite><Author>Park</Author><Year>2012</Year><RecNum>891</RecNum><DisplayText>(4)</DisplayText><record><rec-number>891</rec-number><foreign-keys><key app="EN" db-id="er05av0rndstrmeas51x5wfa0sa5evsv0p0s">891</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Park, S. H.</author><author>Im, C. H.</author><author>Yang, D. H.</author><author>Kang, J. W.</author><author>Yoon, J. Y.</author><author>Cho, H. J.</author><author>Park, H. S.</author><author>Cho, Y.</author><author>Chae, S. C.</author><author>Jun, J. E.</author></authors></contributors><auth-address>Department of Cardiology, Kyungpook National University Hospital, Daegu, Korea.</auth-address><titles><title>A case of chronic periaortitis with retroperitoneal fibrosis</title><secondary-title>Korean Circ J</secondary-title><alt-title>Korean circulation journal</alt-title></titles><periodical><full-title>Korean Circ J</full-title><abbr-1>Korean circulation journal</abbr-1></periodical><alt-periodical><full-title>Korean Circ J</full-title><abbr-1>Korean circulation journal</abbr-1></alt-periodical><pages>857-60</pages><volume>42</volume><number>12</number><dates><year>2012</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>1738-5520 (Print)&#xD;1738-5520 (Linking)</isbn><accession-num>23323126</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/23323126</url></related-urls></urls><custom2>3539054</custom2><electronic-resource-num>10.4070/kcj.2012.42.12.857</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_4" \o "Park, 2012 #891" 4). All possible secondary causes should be evaluated. Tomography or magnetic resonance imaging are useful for diagnosis and follow-up  ADDIN EN.CITE <EndNote><Cite><Author>Park</Author><Year>2012</Year><RecNum>891</RecNum><DisplayText>(4)</DisplayText><record><rec-number>891</rec-number><foreign-keys><key app="EN" db-id="er05av0rndstrmeas51x5wfa0sa5evsv0p0s">891</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Park, S. H.</author><author>Im, C. H.</author><author>Yang, D. H.</author><author>Kang, J. W.</author><author>Yoon, J. Y.</author><author>Cho, H. J.</author><author>Park, H. S.</author><author>Cho, Y.</author><author>Chae, S. C.</author><author>Jun, J. E.</author></authors></contributors><auth-address>Department of Cardiology, Kyungpook National University Hospital, Daegu, Korea.</auth-address><titles><title>A case of chronic periaortitis with retroperitoneal fibrosis</title><secondary-title>Korean Circ J</secondary-title><alt-title>Korean circulation journal</alt-title></titles><periodical><full-title>Korean Circ J</full-title><abbr-1>Korean circulation journal</abbr-1></periodical><alt-periodical><full-title>Korean Circ J</full-title><abbr-1>Korean circulation journal</abbr-1></alt-periodical><pages>857-60</pages><volume>42</volume><number>12</number><dates><year>2012</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>1738-5520 (Print)&#xD;1738-5520 (Linking)</isbn><accession-num>23323126</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/23323126</url></related-urls></urls><custom2>3539054</custom2><electronic-resource-num>10.4070/kcj.2012.42.12.857</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_4" \o "Park, 2012 #891" 4). Erythrocyte sedimentation rate, C-reactive protein level and anti-nuclear antigen levels may be elevated  ADDIN EN.CITE  ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_3" \o "Sakamoto, 2012 #868" 3). Percutaneous biopsy or surgical investigation may be needed to exclude a malignant etiology  ADDIN EN.CITE <EndNote><Cite><Author>Miller</Author><Year>2003</Year><RecNum>968</RecNum><DisplayText>(6)</DisplayText><record><rec-number>968</rec-number><foreign-keys><key app="EN" db-id="er05av0rndstrmeas51x5wfa0sa5evsv0p0s">968</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Miller, O. F.</author><author>Smith, L. J.</author><author>Ferrara, E. X.</author><author>McAleer, I. M.</author><author>Kaplan, G. W.</author></authors></contributors><auth-address>Children&apos;s Hospital and Health Center, San Diego, CA, USA.</auth-address><titles><title>Presentation of idiopathic retroperitoneal fibrosis in the pediatric population</title><secondary-title>J Pediatr Surg</secondary-title><alt-title>Journal of pediatric surgery</alt-title></titles><periodical><full-title>J Pediatr Surg</full-title></periodical><pages>1685-8</pages><volume>38</volume><number>11</number><keywords><keyword>Autoimmune Diseases/complications</keyword><keyword>Azathioprine/therapeutic use</keyword><keyword>Blood Sedimentation</keyword><keyword>Child</keyword><keyword>Combined Modality Therapy</keyword><keyword>Creatinine/blood</keyword><keyword>Disease Progression</keyword><keyword>Humans</keyword><keyword>Hydronephrosis/*etiology</keyword><keyword>Hypertension, Renal/*etiology</keyword><keyword>Immunosuppressive Agents/therapeutic use</keyword><keyword>Kidney Failure, Chronic/*etiology</keyword><keyword>Male</keyword><keyword>Neoplasms/complications</keyword><keyword>Prednisone/therapeutic use</keyword><keyword>Retroperitoneal Fibrosis/*complications/drug therapy/surgery</keyword><keyword>Ureter/surgery</keyword></keywords><dates><year>2003</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1531-5037 (Electronic)&#xD;0022-3468 (Linking)</isbn><accession-num>14614727</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/14614727</url></related-urls></urls></record></Cite></EndNote>( HYPERLINK \l "_ENREF_6" \o "Miller, 2003 #968" 6).
The management of IRF should be individualized. Treatment of hydronephrosis and hypertension can prevent progression of renal insufficiency  ADDIN EN.CITE <EndNote><Cite><Author>Podstawka</Author><Year>2006</Year><RecNum>985</RecNum><DisplayText>(7)</DisplayText><record><rec-number>985</rec-number><foreign-keys><key app="EN" db-id="er05av0rndstrmeas51x5wfa0sa5evsv0p0s">985</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Podstawka, A. J.</author><author>Caban, M. A.</author><author>Mosiewicz, J. Z.</author></authors></contributors><auth-address>Oddzialu Internistyczno-Kardiologicznego oraz Samodzielnego Publicznego Szpitala Wojewodzkiego im. Jana Bozego w Lublinie.</auth-address><titles><title>[Retroperitoneal fibrosis--possible cause of hypertension]</title><secondary-title>Wiad Lek</secondary-title><alt-title>Wiadomosci lekarskie</alt-title></titles><periodical><full-title>Wiad Lek</full-title><abbr-1>Wiadomosci lekarskie</abbr-1></periodical><alt-periodical><full-title>Wiad Lek</full-title><abbr-1>Wiadomosci lekarskie</abbr-1></alt-periodical><pages>135-9</pages><volume>59</volume><number>1-2</number><keywords><keyword>Aged</keyword><keyword>Antihypertensive Agents/therapeutic use</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Hypertension/drug therapy/*etiology</keyword><keyword>Retroperitoneal Fibrosis/*complications/radiography/ultrasonography</keyword><keyword>Tomography, X-Ray Computed</keyword></keywords><dates><year>2006</year></dates><orig-pub>Zwloknienie zaotrzewnowe jako mozliwa przyczyna nadcisnienia tetniczego.</orig-pub><isbn>0043-5147 (Print)&#xD;0043-5147 (Linking)</isbn><accession-num>16646311</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/16646311</url></related-urls></urls></record></Cite></EndNote>( HYPERLINK \l "_ENREF_7" \o "Podstawka, 2006 #985" 7). Steroid therapy is the only acceptable treatment modality; however, its role has not been evaluated in randomized trials  ADDIN EN.CITE <EndNote><Cite><Author>Park</Author><Year>2012</Year><RecNum>891</RecNum><DisplayText>(4)</DisplayText><record><rec-number>891</rec-number><foreign-keys><key app="EN" db-id="er05av0rndstrmeas51x5wfa0sa5evsv0p0s">891</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Park, S. H.</author><author>Im, C. H.</author><author>Yang, D. H.</author><author>Kang, J. W.</author><author>Yoon, J. Y.</author><author>Cho, H. J.</author><author>Park, H. S.</author><author>Cho, Y.</author><author>Chae, S. C.</author><author>Jun, J. E.</author></authors></contributors><auth-address>Department of Cardiology, Kyungpook National University Hospital, Daegu, Korea.</auth-address><titles><title>A case of chronic periaortitis with retroperitoneal fibrosis</title><secondary-title>Korean Circ J</secondary-title><alt-title>Korean circulation journal</alt-title></titles><periodical><full-title>Korean Circ J</full-title><abbr-1>Korean circulation journal</abbr-1></periodical><alt-periodical><full-title>Korean Circ J</full-title><abbr-1>Korean circulation journal</abbr-1></alt-periodical><pages>857-60</pages><volume>42</volume><number>12</number><dates><year>2012</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>1738-5520 (Print)&#xD;1738-5520 (Linking)</isbn><accession-num>23323126</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/23323126</url></related-urls></urls><custom2>3539054</custom2><electronic-resource-num>10.4070/kcj.2012.42.12.857</electronic-resource-num></record></Cite></EndNote>( HYPERLINK \l "_ENREF_4" \o "Park, 2012 #891" 4). Hydronephrosis can be treated with nephrostomy catheters, ureteral stents or ureterolysis  ADDIN EN.CITE <EndNote><Cite><Author>Miller</Author><Year>2003</Year><RecNum>968</RecNum><DisplayText>(6)</DisplayText><record><rec-number>968</rec-number><foreign-keys><key app="EN" db-id="er05av0rndstrmeas51x5wfa0sa5evsv0p0s">968</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Miller, O. F.</author><author>Smith, L. J.</author><author>Ferrara, E. X.</author><author>McAleer, I. M.</author><author>Kaplan, G. W.</author></authors></contributors><auth-address>Children&apos;s Hospital and Health Center, San Diego, CA, USA.</auth-address><titles><title>Presentation of idiopathic retroperitoneal fibrosis in the pediatric population</title><secondary-title>J Pediatr Surg</secondary-title><alt-title>Journal of pediatric surgery</alt-title></titles><periodical><full-title>J Pediatr Surg</full-title></periodical><pages>1685-8</pages><volume>38</volume><number>11</number><keywords><keyword>Autoimmune Diseases/complications</keyword><keyword>Azathioprine/therapeutic use</keyword><keyword>Blood Sedimentation</keyword><keyword>Child</keyword><keyword>Combined Modality Therapy</keyword><keyword>Creatinine/blood</keyword><keyword>Disease Progression</keyword><keyword>Humans</keyword><keyword>Hydronephrosis/*etiology</keyword><keyword>Hypertension, Renal/*etiology</keyword><keyword>Immunosuppressive Agents/therapeutic use</keyword><keyword>Kidney Failure, Chronic/*etiology</keyword><keyword>Male</keyword><keyword>Neoplasms/complications</keyword><keyword>Prednisone/therapeutic use</keyword><keyword>Retroperitoneal Fibrosis/*complications/drug therapy/surgery</keyword><keyword>Ureter/surgery</keyword></keywords><dates><year>2003</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1531-5037 (Electronic)&#xD;0022-3468 (Linking)</isbn><accession-num>14614727</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/14614727</url></related-urls></urls></record></Cite></EndNote>( HYPERLINK \l "_ENREF_6" \o "Miller, 2003 #968" 6). In this case, the patient was accurately diagnosed as IRF and appropriate therapy was performed. By this successful approach the patient was protected from the complication of hypertension and renal failure. 























References

 ADDIN EN.REFLIST 1.	Pipitone N, Vaglio A, Salvarani C. Retroperitoneal fibrosis. Best practice & research Clinical rheumatology. 2012 Aug;26(4):439-48.

2.	Baker LR, Mallinson WJ, Gregory MC, Menzies EA, Cattell WR, Whitfield HN, et al. Idiopathic retroperitoneal fibrosis. A retrospective analysis of 60 cases. Br J Urol. 1987 Dec;60(6):497-503.

3.	Sakamoto A, Nagai R, Saito K, Imai Y, Takahashi M, Hosoya Y, et al. Idiopathic retroperitoneal fibrosis, inflammatory aortic aneurysm, and inflammatory pericarditis--retrospective analysis of 11 case histories. Journal of cardiology. 2012 Mar;59(2):139-46.

4.	Park SH, Im CH, Yang DH, Kang JW, Yoon JY, Cho HJ, et al. A case of chronic periaortitis with retroperitoneal fibrosis. Korean circulation journal. 2012 Dec;42(12):857-60.

5.	Acosta S, Leandersson U, Svensson SE, Johnsen J. [A case report. Endometriosis caused colonic ileus, ureteral obstruction and hypertension]. Lakartidningen. 2001 May 2;98(18):2208-12.

6.	Miller OF, Smith LJ, Ferrara EX, McAleer IM, Kaplan GW. Presentation of idiopathic retroperitoneal fibrosis in the pediatric population. J Pediatr Surg. 2003 Nov;38(11):1685-8.

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Figure Legends

Figure 1. Computed tomography showing encasement of aorta with fibrous tissue (arrows) and right sided hydronephrosis , enlarged renovascular structures (star).

Figure 2. Magnetic resonance imaging revealing resolution of fibrous tissue around the aorta after one month of steroid therapy.

������������O�X�Йљ���ʾ����hee\h�S�CJaJh�S�h�S�CJaJh�S�h�S�5�CJaJh�S�5�CJaJh�S�h�3@CJaJjh�S�h{CJUaJ#h�S�hee\CJaJmHnHsHu	��������N�O�Йљ���������dh`��gd�S�gd�S�,1�h��. ��A!��"��#��$��%��������D<EndNote><Cite><Author>Pipitone</Author><Year>2012</Year><RecNum>864</RecNum><DisplayText>(1)</DisplayText><record><rec-number>864</rec-number><foreign-keys><key app="EN" db-id="er05av0rndstrmeas51x5wfa0sa5evsv0p0s">864</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pipitone, N.</author><author>Vaglio, A.</author><author>Salvarani, C.</author></authors></contributors><auth-address>Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy. Pipitone.nicolo@asmn.re.it</auth-address><titles><title>Retroperitoneal fibrosis</title><secondary-title>Best Pract Res Clin Rheumatol</secondary-title><alt-title>Best practice &amp; research. 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