Managing acute presentations of atheromatous renal artery stenosis

Abstract

Background Atherosclerotic renovascular disease (ARVD) often follows an asymptomatic chronic course which may be undetected for many years. However, there are certain critical acute presentations associated with ARVD and these require a high index of suspicion for underlying high-grade RAS (renal artery stenosis) to improve patient outcomes. These acute presentations, which include decompensated heart failure syndromes, accelerated hypertension, rapidly declining renal function, and acute kidney injury (AKI), are usually associated with bilateral high-grade RAS (> 70% stenosis), or high-grade RAS in a solitary functioning kidney in which case the contralateral kidney is supplied by a vessel demonstrating renal artery occlusion (RAO). These presentations are typically underrepresented in large, randomized control trials which to date have been largely negative in terms of the conferred benefit of revascularization. Case presentation Here we describe 9 individual patients with 3 classical presentations including accelerated phase hypertension, heart failure syndromes, AKI and a fourth category of patients who suffered recurrent presentations. We describe their response to renal revascularization. The predominant presentation was that consistent with ischaemic nephropathy all of whom had a positive outcome with revascularization. Conclusion A high index of suspicion is required for the diagnosis of RAS in these instances so that timely revascularization can be undertaken to restore or preserve renal function and reduce the incidence of hospital admissions for heart failure syndromes.

Severe acute kidney injury in a patient with renal artery stenosis of a single-functioning kidney: A case report of rapid normalisation of the renal function after percutaneous transluminal angioplasty with stent placement

“…According to observational studies and several case reports, a high proportion of patients in an acute setting improves after PTRA, with possible normalisation of renal function. 13 – 20 Furthermore, the rapidity of decline in renal function – which suggests the absence of an irreversible chronic parenchymal damage – is reported to be a good prognostic factor after PTRA. 10 , 30 , 31 A low urine albumin/creatinine ratio (<22.5 mg/g or <2.25 mg/mmol) has also been reported to be a good prognostic factor after PTRA 32 (note, however, that our patient, who was diabetic, had a much higher UACR).…”

“… 9 – 13 In acute settings with rapidly progressive heart and renal failure, BMT versus revascularisation has been only rarely studied and some observational studies have shown improved outcomes in patients who underwent percutaneous transluminal renal angioplasty (PTRA) and stenting of the RAS. 13 – 20 Indeed, some subgroups of patients, including patients with a solitary functioning kidney, 20 – 23 could benefit from this more interventional approach.…”

Elevated serum NLR and PLR are associated with a higher risk of atherosclerotic renal stenosis

“…Failure to identify ARAS promptly can result in progressive deterioration of renal function, end-stage renal disease, and refractory hypertension. Early screening, intervention, and treatment are crucial in preventing the development of ARAS into end-stage renal disease 4 .…”