Working Diagnosis:
Congenital malrotation of the kidney and UPJ obstruction

Treatment:
The athlete underwent a robot-assisted laparoscopic pyeloplasty with a ureteral ureterostomy due to his malrotated kidney with urology. He was discharged on post-operative day 1 with a ureteral stent in place for three weeks with no complications post-operatively. His creatinine improved to 1.58. Despite the intervention, the patient continued to have hypertension, controlled by Norvasc 10mg. He was advised he will likely require lifelong management.

Outcome:
After clearance from the surgeon, he returned to conditioning and practice without concern. He played every game of the season and followed up regularly for blood pressure checks and medication refills.

Author's Comments:
Though athletes in general may have lower rates of hypertension than non-athletes, there have been studies showing higher rates of hypertension in football players, specifically offensive linesman (1). In our patient, the presence of elevated creatinine and his chronic hypertension led to further work up which identified a congenital malrotation of the kidney and a UPJ obstruction. While many cases of hypertension in athletes are either idiopathic, related to poor dietary intake, or medications (2), this case highlights that even in young athlete populations, underlying renal parenchymal disease should not be overlooked.

Editor's Comments:
It is important to note the appropriate way to measure blood pressure. The patient should be sitting in a room, undisturbed, for 5 min with their feet on the floor prior to the measurement being taken. Unfortunately this is not the way most blood pressures are obtained in the training room or group pre-participation exam setting. At least two pressures should be obtained if there is concern for elevated blood pressure. It is important to follow up on elevated blood pressures that arise in the pre-participation evaluation setting. Ambulatory blood pressure monitoring should be considered for any athlete that is seen to have hypertension at the time of an office visit or training room encounter given the possibility of white coat hypertension. Age, sex, and height are taken into consideration for children and adolescents to calculate the percentile within which their blood pressure falls. The appropriate tables should be referenced when interpreting blood pressure in these pediatric age groups. Evaluation of hypertension in athletes should include a detailed history regarding ingested medications, both prescription and over the counter, supplements, alcohol, tobacco, and salt intake. A detailed medical history is also necessary. (2) Secondary causes of hypertension are more common in children than adults. All children diagnosed with hypertension should be evaluated for causes of secondary hypertension where renal disease is the most common cause of secondary hypertension in children.

References:
1. Tucker AM, Vogel RA, Lincoln AE, et al. Prevalence of cardiovascular disease risk factors among National Football League players. JAMA. 2009;301(20):2111-2119.

2. Leddy JJ, Izzo J. Hypertension in athletes. J Clin Hypertens. 2009;11(4):226-233.

Return To The Case Studies List.