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Macrovascular Involvement in Diabetes: Renal Artery Stenosis

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Diabetic Nephropathy

Abstract

The high frequency of both micro- and macrovascular complications in patients with diabetes generates additional challenges for the treatment of patients with renal artery stenosis and the effects of revascularization strategies. First, diabetes is associated with both hypertension and renal dysfunction, obscuring possible causal associations between renal artery stenosis, hypertension, and renal insufficiency. Second, diabetes is associated with impaired renal autoregulation, which may increase the risk of ischemic nephropathy in the stenotic kidney and makes the contralateral kidney particularly vulnerable to the detrimental effects of high blood pressure, and, third, diabetes is associated with renal microvascular disease, which may diminish possible beneficial effects of revascularization in case of renal artery stenosis. At present, randomized trials have not consistently shown that diabetic patients with renal artery stenosis may have less benefit compared to patients without diabetes, although evidence from well-designed trials in patients who are most likely to benefit from revascularization remains limited. In addition to clinical and anatomical criteria, functional assessment of the hemodynamic relevance of renal artery stenosis may be of additional value in selecting patients suitable for revascularization. Currently, there are no data to suggest that clinical criteria for revascularization should be different in diabetic patients with renal artery stenosis, a possible exception being the presence of overt diabetic nephropathy, as defined by the presence of macroalbuminuria. Although there is no evidence that the risk of complications, particularly cholesterol embolism and renal dysfunction, is increased in patients with diabetes and atherosclerotic renal artery stenosis, the risk of contrast nephropathy is higher in patients with diabetes and renal insufficiency. In these cases, preparation with hyperhydration and temporary cessation of metformin should be carried out prior to revascularization.

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Authors and Affiliations

  1. Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands

    Bert-Jan van den Born & Fouad Amraoui

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  1. Bert-Jan van den Born
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  2. Fouad Amraoui
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Correspondence to Bert-Jan van den Born .

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  1. Department of Pathology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands

    Joris J. Roelofs

  2. Department of Internal Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands

    Liffert Vogt

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van den Born, BJ., Amraoui, F. (2019). Macrovascular Involvement in Diabetes: Renal Artery Stenosis. In: Roelofs, J., Vogt, L. (eds) Diabetic Nephropathy. Springer, Cham. https://doi.org/10.1007/978-3-319-93521-8_21

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