Renal Artery Stenosis

Aka: Renal Artery Stenosis, Renovascular Hypertension, Ischemic Nephropathy, Renal Artery Hyperplasia, Renal Artery Fibromuscular Dysplasia

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II. Epidemiology

  1. Renal Artery Stenosis is the most common cause of Secondary Hypertension (1-5%)
  2. Responsible for as much as 25% of Hypertension refractory to medications
  3. Responsible for 10-25% of Severe Hypertension or Malignant Hypertension in white patients

III. Types

  1. Atherosclerotic Renal Artery Stenosis (90%)
    1. Most common cause of Renal Artery Stenosis in age over 65 years old
    2. Associated with comorbid Coronary Artery Disease and Peripheral Arterial Disease
  2. Fibromuscular Dysplasia (10%): Also associated with ruptured aneurysms and dissections
    1. Most common cause of Renal Artery Stenosis in age under 40 years old (especially women)
    2. Sub-types
      1. Medial fibroplasia (most common FMD type, has string of beads appearance on imaging)
      2. Perimedial fibroplasia
      3. Intimal fibroplasia
      4. Adventitial fibroplasia

IV. Evaluation: Diagnostic Clues

  1. Hypertension
    1. Recent onset of Hypertension
      1. Isolated Hypertension is associated with Renal Artery Stenosis in 5% of cases
      2. Up to 40% of those with Hypertension and atherosclerotic disease have Renal Artery Stenosis
      3. Gupta (2017) Curr Cardiol Rep 19(9): 75 [PubMed]
    2. No Family History of Hypertension
    3. Hypertension onset under age 30 or over 55 years
    4. Hypertension with Hypokalemia and Hyponatremia (Hyperaldosterone state)
    5. Hypertension resistant to therapy
      1. Increased Blood Pressure on Diuretic
      2. Excellent response to ACE Inhibitor
      3. ACE Inhibitor increases Serum Creatinine 50% or more over baseline
  2. Comorbid vascular disease
    1. Retinopathy
    2. Systolic or diastolic abdominal bruit
    3. Long History of Tobacco use
    4. Coronary Artery Disease
    5. Cerebrovascular Disease
    6. Peripheral Vascular Disease
  3. Renal dysfunction
    1. Especially Serum Creatinine rise 50% or more over baseline within one week of starting ACE Inhibitors (or ARBs)
      1. Serum Creatinine increase suggests bilateral Renal Artery Stenosis
    2. Recurrent Pulmonary Edema
    3. Asymmetric or bilaterally small Kidneys

V. Labs: Diagnosis (rarely used - imaging is gold standard)

  1. Plasma renin assay before and after ACE Inhibitor
    1. Morning Sample
    2. Unusual to be <3ng/ml/hour in renal vascular disease

VI. Imaging: Diagnosis

  1. Renal artery duplex sonography (Preferred first Screening Test where experienced operators)
    1. Efficacy
      1. Test Sensitivity markedly reduced in Obesity and if significant overlying bowel gas
      2. Operator dependent for accurate results (requires experienced technician)
      3. Test Sensitivity: 75-98%
      4. Test Specificity: 62-99% (Better Specificity than MRA)
    2. Diagnostic Criteria
      1. Peak systolic velocity in renal artery >1.8 to 2.0 m/sec
      2. Renal artery to aortic velocity ratio >3.5
    3. Renal resistive index (RRI) has prognostic value pre-operatively
      1. RRI<80 predicts best Hypertension improvement with revascularization
  2. Magnetic Resonance Angiography (MRA)
    1. Considered preferred Screening Test if sonographer not experienced with RAS screening
    2. Precaution: Gadolinium-Induced Nephrogenic Systemic Fibrosis (nearly always fatal)
      1. Consider alternative screening in Renal Insufficiency (esp. where Serum Creatinine >2.5)
    3. Efficacy
      1. Overestimates extrarenal stenosis
      2. Test Sensitivity: 90-100%
      3. Test Specificity: 76-94%
  3. CT Angiography
    1. Precautions
      1. Do not use if Renal Insufficiency due to Intravenous Contrast material
      2. Significant radiation exposure
    2. Efficacy
      1. Test Sensitivity: 89-100%
      2. Test Specificity: 82-100%
  4. Radionuclide renal scan with and without ACE Inhibitor (Captopril Renography)
    1. Test Sensitivity: 80-100%
    2. Test Specificity: 90%
    3. Safe even in Renal Insufficiency
      1. However not reliable in poor Renal Function or bilateral Renal Artery Stenosis
    4. May help stratify those who will have greatest benefit from RAS intervention
  5. Arteriogram (Angiography)
    1. Gold standard but invasive, interobserver variability, and not used as a Screening Test
  6. References
    1. Hashemi (2011) ARYA Atheroscler 7(2): 58-62 [PubMed]

VII. Management: Medical

  1. See Prevention of Kidney Disease Progression
  2. Optimal medical therapy has equivalent or better outcomes than renal artery stenting in most patients
    1. Cooper (2014) N Engl J Med 370(1): 13-22 [PubMed]
  3. Hypertension control
    1. ACE Inhibitor or Angiotensin Receptor Blocker
      1. Expect some increase in Serum Creatinine
      2. Stop if Serum Creatinine increases 20% in first 4 days of starting (or 30% later)
    2. Diuretics (e.g. Chlorthalidone or Hydrochlorothiazide)
  4. Hyperlipidemia control (goal LDL 70-100)
    1. Statin AntiHyperlipidemics (e.g. Simvastatin)
  5. Maximize Diabetes Mellitus management

VIII. Management: Surgical interventions for revascularization

  1. Indications
    1. Refractory Hypertension on 3 or more medications including a Diuretic
    2. Progressive Azotemia
    3. Acute Renal Failure with ACE Inhibitor (or ARB) with comorbid Congestive Heart Failure
    4. Recurrent flash Pulmonary Edema
    5. Bilateral Renal Artery Stenosis
    6. Stenosis of solitary Kidney
    7. Renal resistive index <0.80
  2. Contraindications (Relative): Factors favoring conservative therapy
    1. Good Hypertension control on 1 or 2 agents
    2. Normal Renal Function
    3. Advanced renal atrophy (<7.5 cm)
    4. Renal resistive index >0.80 (predicts poor Hypertension response to revascularization)
    5. Significant Proteinuria
  3. Procedures
    1. Surgical Revascularization
      1. Rarely used now unless undergoing concurrent open AAA repair
    2. Percutaneous transluminal renal Angioplasty
      1. Stenting has replaced PTRA in most centers due to recoil and recurrent stenosis
    3. Renal artery stenting (preferred first-line test)
  4. Efficacy
    1. Small study suggests outcomes from medical management is equivalent to surgical management
      1. Stenting confers risk (including mortality from massive Cholesterol emboli)
      2. Bax (2009) Ann Intern Med 150(12): 840-8 [PubMed]

IX. Prognosis: Five year survival in atherosclerotic Renal Artery Stenosis

  1. Unilateral Renal Artery Stenosis: 96% five year survival
  2. Bilateral Renal Artery Stenosis: 74% five year survival
  3. Stenosis or Occlusion of solitary Kidney: 47% five year survival
  4. End-stage renal disease on Hemodialysis: 18% five year survival (50% two year survival)

X. References

  1. Shetty (2007) 29th Annual CV Conference, HealthPartners, St. Paul, MN
  2. Firnhaber (2022) Am Fam Physician 105(1): 65-72 [PubMed]
  3. Hartman (2009) Am Fam Physician 80(3): 273-9 [PubMed]

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Related Studies

Ontology: Hypertension, Renovascular (C0020545)

Definition (NCI) High blood pressure secondary to renal artery stenosis.
Definition (MSH) Hypertension due to RENAL ARTERY OBSTRUCTION or compression.
Concepts Disease or Syndrome (T047)
MSH D006978
ICD10 I15.0
SnomedCT 194790006, 123799005
English Hypertension, Renovascular, BP+ - renovascular dis, Secondary renovasc.hypert. NOS, Secondary renovascular hypertension NOS, renovascular hypertension (diagnosis), secondary hypertension renovascular, renovascular hypertension, Renovascular Hypertension, Hypertension, Renovascular [Disease/Finding], hypertension renovascular, Secondary renovascular hypertension NOS (disorder), Hypertension due to renovascular disease, Renovascular hypertension, Renovascular hypertension (disorder), hypertension; renovascular disorders, hypertension; renovascular, renal disease; hypertension, arterial, renovascular; hypertension
Italian Ipertensione renovascolare, Ipertensione nefrovascolare
Japanese 腎血管性高血圧, ｼﾞﾝｹｯｶﾝｾｲｺｳｹﾂｱﾂ
Swedish Hypertoni, renovaskulär
Finnish Munuaisverisuoniperäinen verenpainetauti
Russian GIPERTENZIIA RENOVASKULIARNAIA, GIPERTENZIIA GOL'DBLATTA, GIPERTENZIIA VAZORENAL'NAIA, ГИПЕРТЕНЗИЯ ВАЗОРЕНАЛЬНАЯ, ГИПЕРТЕНЗИЯ ГОЛЬДБЛАТТА, ГИПЕРТЕНЗИЯ РЕНОВАСКУЛЯРНАЯ
German Renovaskulaere Hypertonie, renovaskulaere Hypertonie, Hypertonie, renovaskuläre
Czech Renovaskulární hypertenze, hypertenze renovaskulární, renovaskulární hypertenze
Korean 신혈관 고혈압
Polish Nadciśnienie naczyniowo-nerkowe, Nadciśnienie nerkowo-naczyniowe
Hungarian Renovascularis hypertonia
Norwegian Renovaskulær hypertoni
Spanish hipertensión renovascular secundaria, SAI, hipertensión renovascular secundaria, SAI (trastorno), hipertensión arterial vasculorrenal (trastorno), hipertensión arterial vasculorrenal, hipertensión por enfermedad renovascular, Hipertensión arterial vasculorrenal, Hipertensión Renovascular
Dutch hypertensie; renovasculaire aandoeningen, hypertensie; renovasculair, nieraandoeningen; hypertensie, arterieel, renovasculair; hypertensie, Renovasculaire hypertensie, renovasculaire hypertensie, Hypertensie, renovasculaire, Renovaculaire hypertensie
Portuguese Hipertensão arterial renovascular, Hipertensão Renovascular
French Hypertension rénovasculaire, Hypertension réno-vasculaire, Hypertension rénovasculaire (HTRV), Hypertension vasculo-rénale, Hypertension vasculorénale
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Renal Artery Stenosis (C0035067)

Concepts Disease or Syndrome (T047)
MSH D012078
SnomedCT 83122005, 204481003, 302233006, 282664001
English Renal Artery Stenoses, Renal Artery Stenosis, Stenoses, Renal Artery, Stenosis, Renal Artery, RENAL ARTERY STENOSIS, renal artery stenosis (diagnosis), renal artery stenosis, Renal artery stenosis NOS, Stenosis;artery;renal, arteries renal stenosis, stenosis artery renal, artery renal stenosis, stenosis renal artery, RAS - Renal artery stenosis, Renal artery stenosis, Renal artery stenosis of unknown cause, Renal artery stenosis (disorder), Renal artery stenosis of unknown cause (disorder), renal artery; stenosis, stenosis; artery, renal, stenosis; renal artery, artery; stenosis, renal, Renal artery stenosis, NOS, Renal artery stenosis of unknown cause (disorder) [Ambiguous]
Portuguese ESTENOSE DA ARTERIA RENAL, Estenose NE da artéria renal, Estenose da Artéria Renal, Estenose da artéria renal
Dutch arteria renalis stenose NAO, arterie; stenose, renaal, nierarterie; stenose, stenose; arterie, renaal, stenose; nierarterie, nierarterie stenose, Nierarteriestenose
French Sténose de l'artère rénale SAI, Sténose de l'artère rénale, STENOSE DE L'ARTERE RENALE, Artère rénale sténosée
German Stenose der Nierenarterie NNB, Nierenarterienstenose, NIERENARTERIENSTENOSE
Italian Stenosi dell'arteria renale NAS, Stenosi dell'arteria renale
Spanish Estenosis de la arteria renal NEOM, Estenosis de la Arteria Renal, estenosis de la arteria renal, estenosis de arteria renal (trastorno), estenosis de arteria renal, estenosis de la arteria renal de causa desconocida (concepto no activo), estenosis de la arteria renal de causa desconocida (trastorno), estenosis de la arteria renal de causa desconocida, Estenosis de la arteria renal
Japanese 腎動脈狭窄症, ｼﾞﾝﾄﾞｳﾐｬｸｷｮｳｻｸｼｮｳ, 腎動脈狭窄症ＮＯＳ, ｼﾞﾝﾄﾞｳﾐｬｸｷｮｳｻｸｼｮｳNOS
Czech Stenóza renální tepny, Stenóza renální tepny NOS, stenóza renální arterie
Hungarian arteria renalis stenosis, arteria renalis stenosis k.m.n.
Norwegian Nyrearteriestenose
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Hyperplasia of renal artery (C0155761)

Concepts Disease or Syndrome (T047) , Acquired Abnormality (T020)
ICD9 447.3
ICD10 I77.3
SnomedCT 2900003
English FMH-Fibromus hyperpl, ren art, Fibromusc dysplasia, renal art, Fibromusc hyperpl, renal art, renal artery hyperplasia (diagnosis), renal artery hyperplasia, Renal artery hyperplasia, Fibromuscular hyperplasia (of) renal artery, Renal artery fibromuscular dysplasia, Hyperplasia of renal artery, Fibromuscular hyperplasia of renal artery, FMH - Fibromuscular hyperplasia, of renal artery, Fibromuscular dysplasia of renal artery, Hyperplasia of renal artery (disorder), a.renalis; hyperplasia, hyperplasia; renal artery
Italian Displasia fibromuscolare dell'arteria renale, Iperplasia dell'arteria renale
Dutch hyperplasie arteria renalis, a.renalis; hyperplasie, hyperplasie; arteria renalis, nierarterie fibromusculaire dysplasie, nierarterie hyperplasie
French Hyperplasie de l'artère rénale, Artère rénale hyperplasiée, Dysplasie fibromusculaire de l'artère rénale
German Hyperplasie der Nierenarterie, Fibromuskulaere Dysplasie der Nierenarterie, Nierenarterienhyperplasie
Japanese 腎動脈筋線維性形成異常, 腎動脈過形成, ｼﾞﾝﾄﾞｳﾐｬｸｷﾝｾﾝｲｾｲｹｲｾｲｲｼﾞｮｳ, ｼﾞﾝﾄﾞｳﾐｬｸｶｹｲｾｲ
Czech Fibromuskulární dysplazie renální tepny, Hyperplazie renální tepny
Spanish hiperplasia fibromuscular de la arteria renal (trastorno), hiperplasia de arteria renal (trastorno), hiperplasia de arteria renal, hiperplasia fibromuscular de la arteria renal, hiperplasia de la arteria renal, Displasia fibromuscular de la arteria renal, Hiperplasia de la arteria renal
Hungarian arteria renalis hyperplasia, arteria renalis fibromuscularis dysplasia, renalis arteria hyperplasia
Portuguese Displasia fibromuscular da artéria renal, Hiperplasia da artéria renal
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Ischaemic nephropathy (C2721575)

Concepts Disease or Syndrome (T047)
English Ischemic nephropathy, Ischaemic nephropathy
Spanish Nefropatía isquémica
Portuguese Nefropatia isquémica
French Néphropathie ischémique
Italian Nefropatia ischemica
German Ischaemische Nephropathie
Dutch ischemische nefropathie
Czech Ischemická nefropatie
Japanese 虚血性腎症, ｷｮｹﾂｾｲｼﾞﾝｼｮｳ
Hungarian Ischaemiás nephropathia, Ischemiás nephropathia
Derived from the NIH UMLS (Unified Medical Language System)

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