Challenges in the diagnosis and management of renal artery stenosis

Abstract

Renal artery stenosis (RAS) is a common cause of secondary hypertension, with the activation of the renin-angiotensin-aldosterone system being the pathophysiologic hallmark of the disease. Renovascular hypertension, ischemic nephropathy, proteinuria, and flash pulmonary edema are the main clinical syndromes associated with RAS. The prevalence of RAS is on the rise, owing to an increasing prevalence of diabetes and atherosclerotic disease among our aging population. This rise in RAS prevalence poses major challenges for clinicians making diagnostic and treatment decisions. Although renal angioplasty is of proven benefit in fibromuscular dysplasia, randomized trials in atherosclerotic RAS have not shown any advantage for revascularization over medical therapy in terms of blood pressure control or renal function preservation. Angioplasty and surgical interventions should be reserved for patients with preserved kidney size and hemodynamically significant stenosis.

Posttransplant diabetes and hypertension: Pathophysiologic insights and therapeutic rationale

“…Its incidence ranges from 1% to 23%, depending on the diagnostic criteria used [ 40 ]. The most common location of stenosis is close to the site of anastomosis, but lesions in the iliac artery have been described [ 41 , 42 ].…”

Atherosclerotic process, renovascular disease and outcomes from bench to bedside

“…The increase in blood pressure in RAS is related to the significant activation of the renin-angiotensin-aldosterone axis, triggered by the decreased renal perfusion of the ischemic kidney, resulting in marked vasoconstriction and water and salt retention [3,5]. The goal of the treatment in atherosclerotic RAS is mainly to improve or preserve the function of the stenotic kidney, and intervention is now hardly ever required primarily to control the high blood pressure [8].…”

“…1). Partly because of an increasing prevalence of diabetes and atherosclerotic disease in the aging population [5], incidental atherosclerotic RAS is found in up to 30% of patients undergoing coronary or peripheral vascular angiography [6,7]. In addition, patients now referred for revascularization are older than before (late 60s or early 70s), partly as a result of the more common use of angiotensin-converting enzyme inhibition and angiotensin receptor blockade that effectively controls blood pressure but probably delays the recognition of unsuspected atherosclerotic RAS [8].…”

Renovascular hypertension update

“…Atherosclerotic renal artery stenosis (ARAS), by far the most common lesion producing hypertension, has been reviewed recently [2,7]. Recent epidemiologic studies reconfirm the close association between renovascular disease and cardiovascular morbidity.…”