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The most common cause of obstructive renal artery disease is atherosclerosis, accounting for 90 % of cases of renal artery stenosis. Atherosclerotic renal artery stenosis can be associated with renovascular hypertension, ischemic nephropathy, or both or it may occur alone. The prevalence of atherosclerotic renal artery stenosis among hypertensive patients is estimated between 1 and 5 %, but the frequency rises among patients with refractory hypertension (20 %) coronary heart disease (15 to 20 %) or peripheral arterial disease (30 to 40 %). The gold standard for diagnosing renal artery disease is contrast renal arteriography. MR angiography, CT angiography and color duplex ultrasonography have the highest sensitivity and specifity among the non invasive screening methods. Therapy is based on consequent medical treatment of hypertension, antiplatelet therapy and modification of risk factors for atherosclerosis. Revascularisation is advised in patients with severe hypertension, in patients with pulmonary edema and cases of acute worsening of renal function. Percutaneous angioplasty with stent implantation is the method of choice for revascularisation. The prognosis of patients with atherosclerotic renal artery stenosis is determined by cardiovascular and renal complications.
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PMID:[Atherosclerotic renal artery stenosis]. 1798 55

Diagnosis of renal artery stenosis (RAS) should be discussed in numerous clinical situations including refractory high blood pressure (HBP), HBP in a polyvascular patient, degradation of renal function following renin angiotensin inhibitor or flash pulmonary edema. Ultrasound-doppler coupled with gadolinium-enhanced MR or CT angiography has proven adequate for most patients with RAS. Digital subtraction angiography should be limited to revascularisation procedures. Functional testing are not sensitive or specific enough because the degree of renin activation differs widely among patients with RAS. Renal percutaneous angioplasty induces a light to moderate decrease in blood pressure, has no effect on renal function but allows to reduce the number of anti-hypertensive drugs. Stenting completed angioplasty is worthwhile in most patients with atherosclerotic RAS. ACE inhibitors decrease mortality and increase renal function in patients with RAS.
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PMID:[Why screening for a renal artery stenosis?]. 1803 19

Atherosclerotic renovascular disease (ARVD) is a common manifestation of atheromatous disease. Whilst it usually displays a chronic and asymptomatic course, it is increasingly recognised as playing a significant pathophysiological role in a number of clinical presentations. Anuric acute renal failure (ARF), due to thrombotic renal artery occlusion (RAO) or progression to critical narrowing, however, is a rare complication of this. We report a patient who presented with anuric ARF and pulmonary oedema secondary to bilateral renal artery disease (one chronic RAO, one highly critical renal artery stenosis (RAS)). She showed a good response to renal revascularisation with restoration of renal function, even when this was performed after six days of anuria.
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PMID:Anuric acute renal failure and pulmonary oedema: a case for urgent action. 1804 11

A review of the angioplasty records between 1990 and 1995 at the King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia revealed ten cases of transplant renal artery stenosis (RAS). The diagnosis in these cases was confirmed by renal angiography and all were treated by angioplasty. All study patients presented with uncontrolled hypertension in spite of multiple medications; eight had renal functional impairment and two patients had recurrent unexplained pulmonary edema in addition. Six patients had undergone end-to-end anastomosis, while four had end-to-side anastomosis of the artery during transplantation. Four had cadaveric renal transplants and six had living donor renal transplants. Eight of these patients responded well to angioplasty with marked improvement in their renal function and reduction in the number of anti-hypertensive medications. In one patient, it was not possible to pass the catheter through the stenosis and the patient underwent surgical reconstruction, while in another patient there were multiple stenotic lesions involving the external iliac and the transplant renal arteries suggesting atherosclerotic changes. We conclude that renal artery stenosis should be suspected in patients after renal transplant if they have uncontrolled or worsening hypertension, unexplained renal impairment or presentation with unexplained recurrent pulmonary edema. Renal angiography should be considered as part of the investigation of hypertension in renal transplant patients, and if the RAS is confirmed, angioplasty should be the procedure of choice.
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PMID:Renal artery stenosis in renal transplantation presentation and management. 1840 78

Numerous anatomical and functional changes occurring in the aging kidney lead to reduced glomerular filtration rate, lower renal blood flow and impaired renal autoregulation. The elderly are especially vulnerable to the development of renal dysfunction and in this population acute renal failure (ARF) is a common problem. ARF is often iatrogenic and multifactorial; common iatrogenic combinations include pre-existing renal dysfunction and exposure to nephrotoxins such as radiocontrast agents or aminoglycosides, use of NSAIDs in patients with congestive cardiac failure and use of ACE inhibitors and diuretics in patients with underlying atherosclerotic renal artery stenosis. The aetiology of ARF is classically grouped into three categories: prerenal, intrinsic and postrenal. Prerenal ARF is the second most common cause of ARF in the elderly, accounting for nearly one-third of all hospitalized cases. Common causes can be grouped into true volume depletion (e.g. decreased fluid intake), decreased effective blood volume (e.g. systemic vasodilation) and haemodynamic (e.g. renal artery stenosis, NSAID use). Acute tubular necrosis (ATN) is the most common cause of intrinsic ARF and is responsible for over 50% of ARF in hospitalized patients, and up to 76% of cases in patients in intensive care units. ATN usually occurs after an acute ischaemic or toxic event. The pathogenesis of ATN involves an interplay of processes that include endothelial injury, microvascular flow disruption, tubular hypoxia, dysfunction and apoptosis, tubular obstruction and trans-tubular back-leak. Vasculitis causing ARF should not be missed as this condition is potentially life threatening. The likelihood of a postrenal cause for ARF increases with age. Benign prostatic hypertrophy, prostatic carcinoma and pelvic malignancies are all important causes. Early identification of ARF secondary to obstruction with renal imaging is essential, and complete or partial renal recovery usually ensues following relief of the obstruction.A comprehensive medical and drug history and physical examination are all invaluable. Particular attention should be paid to the fluid status of the patient (skin turgor, jugular venous pressure, lying and standing blood pressure, urine output). Urinalysis should be performed to detect evidence of proteinuria and haematuria, which will aid diagnosis. Fractional excretion of sodium and urine osmolality may be measured but the widespread use of diuretics in the elderly gives rise to unreliable results. Renal imaging, usually ultrasound scanning, is routinely performed for assessment of renal size and to exclude urinary obstruction. In some cases, renal biopsy is necessary to provide specific diagnostic information. The general principles of managing ARF include treatment of life-threatening features such as shock, respiratory failure, hyperkalaemia, pulmonary oedema, metabolic acidosis and sepsis; stopping and avoiding administration of nephrotoxins; optimization of haemodynamic and fluid status; adjustment of drug dosage appropriate to glomerular filtration rate; early nutritional support; and early referral to nephrologists for diagnosis of ARF cause, timely initiation of dialysis and initiation of specific treatment. The treatment of prerenal and ATN ARF is largely supportive with little evidence of benefit from current pharmacological therapies. Despite advances in critical care medicine and renal replacement therapy, the mortality of ARF has not changed significantly over the last 40 years, with current mortality rates being up to 75%.
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PMID:Management of acute renal failure in the elderly patient: a clinician's guide. 1854 Jun 87

In patients with severe hypertension a search for a renal cause, particularly for a renal artery stenosis, needs to be undertaken with 24-hour blood pressure measurement, urinary examination, determination of renal function and duplex sonography of the kidneys.--Sympathetic hyperactivity, which is associated with an increased cardiovascular risk, may already be found in an early stage of renal diseases. There is evidence that administration of an ACE inhibitor or an angiotensin receptor antagonist (ARB) may induce a decrease of sympathetic hyperactivity as well as a reduced rate of adverse cardiovascular events in patients in renal failure.--In patients with renal disease and high proteinuria antihypertensive therapy with ACE-inhibitors or ARB delays the progression of chronic renal failure. Combined therapy of ACE-inhibitors plus ARB may reduce proteinuria more than that would be the case with either of these drugs alone. However, there is no evidence that combination of these two drugs improves renal function more than monotherapy.--Renal artery stenosis of > 70% should be treated by dilatation, if there is evidence of fibromuscular dysplasia. Dilatation and/or stent implantation in an atherosclerotic renal artery stenosis of > 70% should be performed if indicated by the patient's clinical state. i.e. severe hypertension has proved to be resistant to triple drug antihypertensive therapy or pulmonary edema has occurred frequently. Preservation of renal function by angioplasty of an atherosclerotic renal artery stenosis remains a challenge. However, exact criteria for such intervention need to be established. But so far there have not been adequate data from controlled prospective trials.
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PMID:[The kidneys and hypertension]. 1877 Apr 87

Atherosclerotic renal artery stenosis is the most common cause of renovascular hypertension. Primary treatment of renal artery stenosis includes renal artery balloon angioplasty and, in some cases, renal artery stenting. However, in-stent restenosis occurs in 11% to 39% of patients thus treated. Herein, we report the case of a 76-year-old woman whose left-sided renal artery stenosis had been treated by means of renal artery stenting. She later presented at our institution with flash pulmonary edema that was caused by in-stent restenosis. We successfully treated the patient with cutting-balloon angioplasty and cryoplasty of the in-stent restenosis. To our knowledge, this is the 1st report of the use of cryotherapy to treat in-stent renal artery stenosis.
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PMID:First use of cryoplasty to treat in-stent renal artery restenosis. 1915 53

Renal artery stenosis may be due to atheromatous disease or renal fibromuscular dysplasia (FMD). Management of both diseases requires treatment of hypertension usually observed in such patients; however, clinical presentation, mechanism and treatment of these 2 diseases are usually different. Renal FMD is now considered as a systemic disease, the cause of which may be genetic (although the exact cause is still elusive). Renal arteries are the most frequent localizations of FMD, but extra renal arteries may also be involved (usually carotid arteries). Risk factors of hypertension-induced renal FMD include estrogen treatment and smoking. Renal FMD are mostly found in young women and in children who present with recent severe and/or refractory symptomatic hypertension. Diagnosis is usually easy (Doppler, CT-scan), and treatment of renal FMD is angioplasty in most cases. Atheromatous renal artery stenosis is usually found in patients with other atheromatous disease (peripheral artery disease, carotid, coronary artery disease...). Clinical presentation include severe or refractory hypertension, recurrent flash pulmonary edema in a patient with hypertension, progressive renal dysfunction spontaneously or after medical treatment with converting-enzyme inhibition or angiotensin II blockade, hypertension in a patient (usually smoker or ex-smoker) with diffuse atheromatous vascular disease. Management of atheromatous renal artery disease is medical treatment in all patients (aggressive treatment of cardiovascular risk factors, control of arterial pressure); revascularization is required in some patients only since it rarely cures hypertension: the goal of revascularization is mostly renal function protection, which may be observed in selected patients. Revascularization must be decided by physicians or teams involved in the care of such patients. Patients with atheromatous renal artery disease are at very high renal and cardiovascular risk : aggressive management of cardiovascular risk factors is crucial.
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PMID:[Renal artery stenosis : atheromatous disease and fibromuscular dysplasia]. 1921 51

Atherosclerotic renal artery stenosis affects between 2 and 4 million people in the United States alone and likely has a higher prevalence than previously thought. Renal artery stenosis has been increasingly recognized in recent years, especially in patients with cardiovascular disease. It has been associated with hypertension, renal dysfunction, and sudden onset of pulmonary edema. Patients with symptomatic and hemodynamically significant renal artery stenosis are candidates for revascularization. Revascularization is most often accomplished by renal artery stenting, which has high success rates in terms of patency and low complication rates. An important element in managing patients with renal artery stenosis is selecting those patients who are most likely going to benefit from revascularization. This review article focuses on the clinical diagnosis, current treatment options, and future directions regarding treatment of patients with renal artery stenosis.
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PMID:Atherosclerotic renal artery stenosis: current therapy and future developments. 1961 89

Screening for renal artery stenosis (RAS) should be restricted to patients with a high RAS risk. Captopril renography, computed tomography (CT)-angiography, magnetic resonance (MR)-angiography and ultrasound (US) Doppler can be used. Most patients should receive medical treatment. If predictive tests suggest a good outcome, revascularisation with percutaneous transluminal renal angioplasty (PTRA) should be considered in patients with refractory hypertension, fibromuscular dysplasia, recurrent pulmonary oedema, bilateral renal artery stenosis or progressive azotaemia, and in patients with a narrow stenosis to a single kidney.
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PMID:[Renal artery stenosis--diagnosis and treatment]. 1967 91


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