Typically due to atherosclerotic disease or fibromuscular dysplasia.
Often presents with accelerated or difficult-to-control hypertension.
Worsening kidney function, especially after initiating renin-angiotensin blockade, and recurrent flash pulmonary edema are common features.
Presence of renal artery narrowing does not necessarily indicate clinical consequences. Renal artery stenosis, renovascular hypertension, and ischemic nephropathy are various manifestations of this process.
Definitive diagnosis is with imaging.
Renal artery stenosis (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. Ischemic 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
- onset of hypertension age >55 years
- history of accelerated, malignant, or resistant hypertension
- history of unexplained kidney dysfunction
- history of multivessel coronary artery disease
- history of other peripheral vascular disease
- abdominal bruit
- sudden or unexplained recurrent pulmonary edema
- 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 hypokalemia
- 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
- noncontrast magnetic resonance angiography
- captopril radionuclide renal scan
Rohit Malhotra, MBBS
Interventional Cardiology Fellow
Mount Sinai Hospital
RM declares that he has no competing interests.
Alvaro Alonso, MD, FSVM
Assistant Professor of Medicine
University of Massachusetts Medical School
UMass Memorial Medical Center
AA declares that he has no competing interests.
RM and AA would like to gratefully acknowledge Dr Manmeet Singh and Dr Scott J. Gilbert, previous contributors to this topic. MS and SJG declare that they have no competing interests.
Robert Tompkins, MD
Department of Family Medicine
University of Texas Health Science Center
RT declares that he has no competing interests.
Irfan Moinuddin, MD
Chicago Medical School
Rosalind Franklin University
IM declares that he has no competing interests.
John Webster, MD
Aberdeen Royal Infirmary
JW declares that he has no competing interests.
Neil A. Kurtzman, MD
Grover E. Murray Professor
University Distinguished Professor
Texas Tech University Medical Center
NAK declares that he has no competing interests.
- Essential hypertension
- Acute kidney injury
- Renal artery dissection
- 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS)
- 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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