片側腎動脈狭窄および対側機能温存患者におけるフラッシュ肺水腫：医学的治療による症例報告

Flash pulmonary oedema (Pickering phenotype) is a high-risk, under-recognised manifestation of renovascular disease. A man in his 50s presented with abrupt dyspnoea, hypertensive crisis, type 1 respiratory failure, and pulmonary oedema. His response to intravenous diuretics was limited, and he was stabilised in the ICU with glyceryl trinitrate and continuous positive airway pressure. Ultrasound showed a small scarred right kidney of 7.9 cm. Echocardiography found a left ventricular ejection fraction (LVEF) of 25% at presentation. Three months later, cardiac MRI showed LVEF of 40% with diffuse mid-wall scarring. Renal MR angiography (MRA) confirmed severe ostial right renal artery stenosis, and dimercaptosuccinic acid (DMSA) demonstrated a split kidney function of 36% in the right and 64% in the left. A medical-first strategy was chosen after multidisciplinary discussion, with no recurrent episodes of pulmonary oedema during follow-up. This case illustrates the difficulty of attributing flash pulmonary oedema to unilateral atherosclerotic renovascular disease in the context of long-standing hypertensive heart and kidney disease and highlights how laterality, kidney size, and differential function can guide the choice between selective revascularisation and conservative management.