{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T11:20:50Z","timestamp":1785410450652,"version":"3.56.0"},"reference-count":8,"publisher":"Department of Medicine, Warren Alpert Medical School at Brown University","issue":"2","license":[{"start":{"date-parts":[[2026,4,1]],"date-time":"2026-04-01T00:00:00Z","timestamp":1775001600000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:p>Pickering syndrome is an uncommon but clinically significant manifestation of renovascular disease, classically characterized by recurrent hypertensive emergencies and flash pulmonary edema in the setting of bilateral renal artery stenosis or unilateral stenosis in a solitary functioning kidney. Focal intrarenal or segmental renal artery stenosis is an underrecognized anatomic pattern that may produce similar physiologic effects and may be overlooked when diagnostic evaluation is limited to the main renal arteries. We report the case of a 34-year-old woman with recurrent hypertensive emergencies complicated by flash pulmonary edema, preserved left ventricular systolic function, and progressive renal dysfunction. Renal duplex Doppler ultrasonography demonstrated abnormal intrarenal hemodynamics confined to an upper-pole segmental artery of the left kidney, including absent end-diastolic flow and a markedly elevated resistive index (RI = 1.0), while flow velocities in the main renal arteries were normal. These intrarenal Doppler findings, in the setting of reduced renal functional reserve and recurrent cardiopulmonary decompensation, were suggestive of Pickering physiology. This case highlights probable focal intrarenal renovascular disease as a potential and underrecognized cause of Pickering physiology and underscores the diagnostic value of comprehensive intrarenal Doppler waveform analysis, as reliance on main renal artery assessment alone may fail to identify functionally significant segmental disease. Recognition of regional disparities in intrarenal flow patterns can provide critical diagnostic insight, particularly when cross-sectional angiographic imaging is not feasible. In patients with reduced renal functional reserve, even focal segmental renovascular disease may produce severe systemic hemodynamic consequences, emphasizing the need for heightened diagnostic vigilance.<\/jats:p>","DOI":"10.56305\/001c.159171","type":"journal-article","created":{"date-parts":[[2026,4,1]],"date-time":"2026-04-01T16:51:34Z","timestamp":1775062294000},"source":"Crossref","is-referenced-by-count":0,"title":["Pickering Syndrome Physiology from Focal Intrarenal Segmental Renal Artery Stenosis: An Under Recognized Cause of Recurrent Hypertensive Emergencies"],"prefix":"10.56305","volume":"5","author":[{"ORCID":"https:\/\/orcid.org\/0009-0000-2895-9043","authenticated-orcid":true,"given":"David Kweku Aseda","family":"Donkor","sequence":"first","affiliation":[{"id":[{"id":"https:\/\/ror.org\/01kaqt385","id-type":"ROR","asserted-by":"publisher"}],"name":"WellStar Health System","department":["Department of Internal Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ruth","family":"Abebe","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/01kaqt385","id-type":"ROR","asserted-by":"publisher"}],"name":"WellStar Health System","department":["Department of Internal Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Raghavendramma","family":"Barremkala","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/01kaqt385","id-type":"ROR","asserted-by":"publisher"}],"name":"WellStar Health System","department":["Department of Internal Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1925-0563","authenticated-orcid":false,"given":"Parth","family":"Adrejiya","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/01kaqt385","id-type":"ROR","asserted-by":"publisher"}],"name":"WellStar Health System","department":["Department of Internal Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Madhu","family":"Chandra","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/01kaqt385","id-type":"ROR","asserted-by":"publisher"}],"name":"WellStar Health System","department":["Department of Internal Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gaurav","family":"Dutta","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/01z1vct10","id-type":"ROR","asserted-by":"publisher"}],"name":"City of Hope","department":["Division of Pulmonary and Critical Care Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"35509","published-online":{"date-parts":[[2026,4,1]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"2231","DOI":"10.1093\/eurheartj\/ehr056","article-title":"Flash pulmonary oedema and bilateral renal artery stenosis: the Pickering syndrome","volume":"32","author":"F. H. Messerli","year":"2011","journal-title":"Eur Heart J"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"15","DOI":"10.3109\/08037051.2010.527445","article-title":"Flash pulmonary edema in patients with renal artery stenosis \u2013 the Pickering syndrome","volume":"20","author":"A. Pelta","year":"2011","journal-title":"Blood Press"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"e030474","DOI":"10.1161\/JAHA.123.030474","article-title":"Pickering syndrome: an overlooked renovascular cause of recurrent heart failure","volume":"12","author":"V. Sanga","year":"2023","journal-title":"J Am Heart Assoc"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"2618","DOI":"10.1016\/j.radcr.2023.04.063","article-title":"Pickering syndrome in a patient with a single kidney: role of renal artery stenting","volume":"18","author":"A. Malas","year":"2023","journal-title":"Radiol Case Rep"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"e244402","DOI":"10.1136\/bcr-2021-244402","article-title":"Unilateral renal artery stenosis causing hypertensive flash pulmonary oedema","volume":"14","author":"M. I. Derakhshesh","year":"2021","journal-title":"BMJ Case Rep"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"e35228","DOI":"10.1097\/MD.0000000000035228","article-title":"Recurrent flash pulmonary edema in unilateral renal artery stenosis with contralateral kidney shrinkage: a case report","volume":"102","author":"J. E. Cheon","year":"2023","journal-title":"Medicine (Baltimore)"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"57","DOI":"10.3348\/kjr.2001.2.1.57","article-title":"Detection of segmental branch renal artery stenosis by Doppler US: a case report","volume":"2","author":"C. K. Seong","year":"2001","journal-title":"Korean J Radiol"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"4","DOI":"10.1007\/s00772-015-0060-3","article-title":"Ultrasound diagnostics of renal artery stenosis: stenosis criteria, CEUS and recurrent in-stent stenosis","volume":"21","author":"W. Sch\u00e4berle","year":"2016","journal-title":"Gefasschirurgie"}],"container-title":["Journal of Brown Hospital Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/bhm.scholasticahq.com\/article\/159171-pickering-syndrome-physiology-from-focal-intrarenal-segmental-renal-artery-stenosis-an-under-recognized-cause-of-recurrent-hypertensive-emergencies","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,1]],"date-time":"2026-04-01T16:51:35Z","timestamp":1775062295000},"score":1,"resource":{"primary":{"URL":"https:\/\/bhm.scholasticahq.com\/article\/159171-pickering-syndrome-physiology-from-focal-intrarenal-segmental-renal-artery-stenosis-an-under-recognized-cause-of-recurrent-hypertensive-emergencies"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,1]]},"references-count":8,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026]]}},"URL":"https:\/\/doi.org\/10.56305\/001c.159171","relation":{},"ISSN":["2994-5593"],"issn-type":[{"value":"2994-5593","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,1]]}}}