Renal artery stenosis (RAS) is typically due to atherosclerotic disease or fibromuscular dysplasia.
RAS often presents with accelerated or difficult-to-control hypertension.
Worsening kidney function, especially after initiating renin-angiotensin blockade, and recurrent flash pulmonary oedema are common features.
Presence of renal artery narrowing does not necessarily indicate clinical consequences. Renal artery stenosis, renovascular hypertension, and ischaemic nephropathy are various manifestations of this process.
Definitive diagnosis is with imaging.
Management typically involves medical therapy, with revascularisation reserved for selected high-risk or severe cases.
RAS is a narrowing of the renal artery lumen. It is considered angiographically significant if more than a 50% reduction in vessel diameter is present. Ischaemic nephropathy is a chronic reduction in glomerular filtration rate that occurs from a narrowing in the renal artery. Renovascular hypertension is hypertension mediated by high levels of renin and angiotensin II, produced by an underperfused kidney supplied by a stenosed renal artery.
History and exam
Key diagnostic factors
- presence of key risk factors
- onset of hypertension age >55 years
- history of accelerated, malignant, or resistant hypertension
- history of unexplained kidney dysfunction
- history of multi-vessel coronary artery disease
- history of other peripheral vascular disease
- abdominal bruit
- sudden or unexplained recurrent pulmonary oedema
- onset of hypertension age <30 years
Other diagnostic factors
- absence of family history of hypertension
- other bruits
- history of acute kidney injury after administration of ACE inhibitor or angiotensin II receptor antagonist
- history of unexplained congestive heart failure
- refractory angina
- history of hypokalaemia
- female sex
1st investigations to order
- serum creatinine
- serum potassium
- urinalysis and sediment evaluation
- aldosterone-to-renin ratio
Investigations to consider
- duplex ultrasound
- gadolinium-enhanced MR angiography (MRA)
- CT angiography
- conventional angiography
- carbon dioxide (CO2) angiography
- non-contrast magnetic resonance angiography
- captopril radionuclide renal scan
- Essential hypertension
- Acute kidney injury
- Renal artery dissection
- ACR appropriateness criteria: renovascular hypertension
- 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines
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