Renal artery stenosis

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Renal artery stenosis
Classification and external resources
Kidney PioM.png
ICD-10 I70.1
ICD-9 440.1
DiseasesDB 11255
MedlinePlus 001273
eMedicine med/2001
MeSH D012078

Renal artery stenosis is the narrowing of the renal artery, most often caused by atherosclerosis or fibromuscular dysplasia. This narrowing of the renal artery can impede blood flow to the target kidney. High blood pressure and atrophy of the affected kidney may result from renal artery stenosis, ultimately leading to kidney failure if not treated.

Signs and symptoms[edit]

Most cases of renal artery stenosis are asymptomatic, and the main problem is high blood pressure that cannot be controlled with medication. Deterioration in kidney function may develop if both kidneys do not receive adequate blood flow, or when treatment with an ACE inhibitor is initiated. Some people with renal artery stenosis present with episodes of flash pulmonary edema (sudden left ventricular heart failure).[1]

Diagnosis[edit]

The gold standard investigation to diagnose renal artery stenosis is digital subtraction angiography.[2]

A clinical prediction rule is available to guide diagnosis.[4]

Cause[edit]

Atherosclerosis is the predominant cause of renal artery stenosis in the majority of patients, usually those with a sudden onset of hypertension at age 50 or older. Fibromuscular dysplasia is the predominant cause in young patients, usually females under 40 years of age. A variety of other causes exist. These include arteritis, renal artery aneurysm, extrinsic compression (e.g., neoplasms), neurofibromatosis, and fibrous bands.

Pathophysiology[edit]

The granular cells of the afferent arteriole senses a decreased systemic blood pressure owing to the reduced blood flow through the narrowed artery. The response of the kidney to this perceived decreased blood pressure is activation of the renin-angiotensin aldosterone system, which normally counteracts low blood pressure but in this case leads to hypertension (high arterial blood pressure). The decreased perfusion pressure (caused by the stenosis) leads to decreased blood flow (hypoperfusion) to the kidney and a decrease in the GFR. If the stenosis is longstanding and severe the GFR in the affected kidneys never increases again and (prerenal) kidney failure is the result.

Treatment[edit]

Atherosclerotic renal artery stenosis[edit]

It is initially treated with medications. These include statins, antiplatelet agents and drugs for control of blood pressure. When high-grade renal artery stenosis is documented and blood pressure cannot be controlled with medication, or if renal function deteriorates, invasive procedure may be resorted to.

The most commonly used invasive procedure is angioplasty with or without stenting. It is unclear if this is better than simply the use of medications.[5] It is a relatively safe procedure.[5]

If all else fails and the kidney is thought to be worsening hypertension and revascularization with angioplasty or surgery does not work, then surgical removal of the affected kidney (nephrectomy) may significantly improve high blood pressure.

Fibromuscular dysplasia[edit]

Angioplasty with or without stenting is the best option for the treatment of renal artery stenosis due to fibromuscular dysplasia.

See also[edit]

References[edit]

  1. ^ Pickering TG, Herman L, Devereux RB et al. (1988). "Recurrent pulmonary oedema in hypertension due to bilateral renal artery stenosis: treatment by angioplasty or surgical revascularisation". Lancet 2 (8610): 551–2. doi:10.1016/S0140-6736(88)92668-2. PMID 2900930. 
  2. ^ Sam, Amir H.; James T.H. Teo (2010). Rapid Medicine. Wiley-Blackwell. ISBN 1405183233. 
  3. ^ Roccatello D, Picciotto G (1997). "Captopril-enhanced scintigraphy using the method of the expected renogram: improved detection of patients with renin-dependent hypertension due to functionally significant renal artery stenosis" (PDF). Nephrol. Dial. Transplant. 12 (10): 2081–6. doi:10.1093/ndt/12.10.2081. PMID 9351069. 
  4. ^ Krijnen P, van Jaarsveld BC, Steyerberg EW, Man in 't Veld AJ, Schalekamp MA, Habbema JD (1998). "A clinical prediction rule for renal artery stenosis". Ann. Intern. Med. 129 (9): 705–11. doi:10.7326/0003-4819-129-9-199811010-00005. PMID 9841602. 
  5. ^ a b Jenks, S; Yeoh, SE; Conway, BR (5 December 2014). "Balloon angioplasty, with and without stenting, versus medical therapy for hypertensive patients with renal artery stenosis.". The Cochrane database of systematic reviews 12: CD002944. PMID 25478936.