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Renal Artery Stenosis: Diagnosis and Management

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Cardio-Nephrology

Abstract

Renal artery stenosis (RAS) is commonly atherosclerotic in origin and its incidence increases with age. Decreased renal perfusion causes renal ischemia, which activates the renin–angiotensin–aldosterone system and increases a variety of inflammatory and pro-fibrotic cytokines. This results in the development of hypertension and a decline in renal function. Unfortunately, the finding of renal artery stenosis does not always imply the presence of renal ischemia. Several randomized controlled trials have not demonstrated a benefit of renal artery revascularization over medical treatment with anti-hypertensive and lipid-lowering medications in regards to either blood pressure control or renal outcomes. All these trials have been faulted for including low-risk subjects who would not be expected to benefit from revascularization. It is clear that the majority of patients with RAS can be treated with medical therapy alone. The question is how to identify those patients who would benefit from revascularization. High-risk patients include those with resistant hypertension, unexplained worsening renal function, asymmetric renal size, and recurrent episodes of flash pulmonary. Those individuals should be evaluated by non-invasive imaging techniques. If a greater than 70% stenosis is found, renal arteriography should be performed. It is important to recognize, however, that even if a greater than 70% stenosis is confirmed on arteriography, this does not necessarily indicate the presence of renal ischemia. Several newer methodologies including BOLD MRI, dynamic contrast enhanced MRI and renal frame count have, in small studies, been shown to correlate with the presence of renal ischemia. Unfortunately, whether such techniques will actually be able to identify those patients who will benefit from revascularization will have to await larger trials. Until then the clinician will need to use his/her best judgement in the treatment of this disorder.

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Authors and Affiliations

  1. Department of Nephrology, Baylor University Medical Center, 3600 Gaston Ave, Barnett Tower, Suite 904, 75246, Dallas, TX, USA

    Harold M. Szerlip

  2. Cardio Renal Society of America, 3219 East Camelback Road, Suite 517, 85018, Phoenix, AZ, USA

    Bhupinder Singh

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Correspondence to Harold M. Szerlip .

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Editors and Affiliations

  1. Department of Internal Medicine, Einstein Medical Center, Sidney Kimmel College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA

    Janani Rangaswami

  2. Department of Medicine, Section of Nephrology, University of Illinois at Chicago, Chicago, Illinois, USA

    Edgar V. Lerma

  3. Department of Nephrology Dialysis and Transplantation, International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy

    Claudio Ronco

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Szerlip, H.M., Singh, B. (2017). Renal Artery Stenosis: Diagnosis and Management. In: Rangaswami, J., Lerma, E., Ronco, C. (eds) Cardio-Nephrology. Springer, Cham. https://doi.org/10.1007/978-3-319-56042-7_40

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  • DOI: https://doi.org/10.1007/978-3-319-56042-7_40

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