II. Epidemiology
- Renal Artery Stenosis is the most common cause of Secondary Hypertension (1-5%)
- Responsible for as much as 25% of Hypertension refractory to medications
- Responsible for 10-25% of Severe Hypertension or Malignant Hypertension in white patients
III. Types
- Atherosclerotic Renal Artery Stenosis (90%)
- Most common cause of Renal Artery Stenosis in age over 65 years old
- Associated with comorbid Coronary Artery Disease and Peripheral Arterial Disease
- Fibromuscular Dysplasia (10%): Also associated with ruptured aneurysms and dissections
- Most common cause of Renal Artery Stenosis in age under 40 years old (especially women)
- Sub-types
- Medial fibroplasia (most common FMD type, has string of beads appearance on imaging)
- Perimedial fibroplasia
- Intimal fibroplasia
- Adventitial fibroplasia
IV. Evaluation: Diagnostic Clues
-
Hypertension
- Recent onset of Hypertension
- Isolated Hypertension is associated with Renal Artery Stenosis in 5% of cases
- Up to 40% of those with Hypertension and atherosclerotic disease have Renal Artery Stenosis
- Gupta (2017) Curr Cardiol Rep 19(9): 75 [PubMed]
- No Family History of Hypertension
- Hypertension onset under age 30 or over 55 years
- Hypertension with Hypokalemia and Hyponatremia (Hyperaldosterone state)
-
Hypertension resistant to therapy
- Increased Blood Pressure on Diuretic
- Excellent response to ACE Inhibitor
- ACE Inhibitor increases Serum Creatinine 50% or more over baseline
- Recent onset of Hypertension
- Comorbid vascular disease
- Retinopathy
- Systolic or diastolic abdominal bruit
- Long History of Tobacco use
- Coronary Artery Disease
- Cerebrovascular Disease
- Peripheral Vascular Disease
- Renal dysfunction
- Especially Serum Creatinine rise 50% or more over baseline within one week of starting ACE Inhibitors (or ARBs)
- Serum Creatinine increase suggests bilateral Renal Artery Stenosis
- Recurrent Pulmonary Edema
- Asymmetric or bilaterally small Kidneys
- Especially Serum Creatinine rise 50% or more over baseline within one week of starting ACE Inhibitors (or ARBs)
V. Labs: Diagnosis (rarely used - imaging is gold standard)
- Plasma renin assay before and after ACE Inhibitor
- Morning Sample
- Unusual to be <3ng/ml/hour in renal vascular disease
VI. Imaging: Diagnosis
- Renal artery duplex sonography (Preferred first Screening Test where experienced operators)
- Efficacy
- Test Sensitivity markedly reduced in Obesity and if significant overlying bowel gas
- Operator dependent for accurate results (requires experienced technician)
- Test Sensitivity: 75-98%
- Test Specificity: 62-99% (Better Specificity than MRA)
- Diagnostic Criteria
- Peak systolic velocity in renal artery >1.8 to 2.0 m/sec
- Renal artery to aortic velocity ratio >3.5
- Renal resistive index (RRI) has prognostic value pre-operatively
- RRI<80 predicts best Hypertension improvement with revascularization
- Efficacy
- Magnetic Resonance Angiography (MRA)
- Considered preferred Screening Test if sonographer not experienced with RAS screening
- Precaution: Gadolinium-Induced Nephrogenic Systemic Fibrosis (nearly always fatal)
- Consider alternative screening in Renal Insufficiency (esp. where Serum Creatinine >2.5)
- Efficacy
- Overestimates extrarenal stenosis
- Test Sensitivity: 90-100%
- Test Specificity: 76-94%
- CT Angiography
- Precautions
- Do not use if Renal Insufficiency due to Intravenous Contrast material
- Significant radiation exposure
- Efficacy
- Test Sensitivity: 89-100%
- Test Specificity: 82-100%
- Precautions
- Radionuclide renal scan with and without ACE Inhibitor (Captopril Renography)
- Test Sensitivity: 80-100%
- Test Specificity: 90%
- Safe even in Renal Insufficiency
- However not reliable in poor Renal Function or bilateral Renal Artery Stenosis
- May help stratify those who will have greatest benefit from RAS intervention
- Arteriogram (Angiography)
- Gold standard but invasive, interobserver variability, and not used as a Screening Test
- References
VII. Management: Medical
- See Prevention of Kidney Disease Progression
- Optimal medical therapy has equivalent or better outcomes than renal artery stenting in most patients
-
Hypertension control
- ACE Inhibitor or Angiotensin Receptor Blocker
- Expect some increase in Serum Creatinine
- Stop if Serum Creatinine increases 20% in first 4 days of starting (or 30% later)
- Diuretics (e.g. Chlorthalidone or Hydrochlorothiazide)
- ACE Inhibitor or Angiotensin Receptor Blocker
-
Hyperlipidemia control (goal LDL 70-100)
- Statin AntiHyperlipidemics (e.g. Simvastatin)
- Maximize Diabetes Mellitus management
VIII. Management: Surgical interventions for revascularization
- Indications
- Refractory Hypertension on 3 or more medications including a Diuretic
- Progressive Azotemia
- Acute Renal Failure with ACE Inhibitor (or ARB) with comorbid Congestive Heart Failure
- Recurrent flash Pulmonary Edema
- Bilateral Renal Artery Stenosis
- Stenosis of solitary Kidney
- Renal resistive index <0.80
- Contraindications (Relative): Factors favoring conservative therapy
- Good Hypertension control on 1 or 2 agents
- Normal Renal Function
- Advanced renal atrophy (<7.5 cm)
- Renal resistive index >0.80 (predicts poor Hypertension response to revascularization)
- Significant Proteinuria
- Procedures
- Surgical Revascularization
- Rarely used now unless undergoing concurrent open AAA repair
- Percutaneous transluminal renal Angioplasty
- Stenting has replaced PTRA in most centers due to recoil and recurrent stenosis
- Renal artery stenting (preferred first-line test)
- Surgical Revascularization
- Efficacy
- Small study suggests outcomes from medical management is equivalent to surgical management
- Stenting confers risk (including mortality from massive Cholesterol emboli)
- Bax (2009) Ann Intern Med 150(12): 840-8 [PubMed]
- Small study suggests outcomes from medical management is equivalent to surgical management
IX. Prognosis: Five year survival in atherosclerotic Renal Artery Stenosis
- Unilateral Renal Artery Stenosis: 96% five year survival
- Bilateral Renal Artery Stenosis: 74% five year survival
- Stenosis or Occlusion of solitary Kidney: 47% five year survival
- End-stage renal disease on Hemodialysis: 18% five year survival (50% two year survival)
X. References
- Shetty (2007) 29th Annual CV Conference, HealthPartners, St. Paul, MN
- Firnhaber (2022) Am Fam Physician 105(1): 65-72 [PubMed]
- Hartman (2009) Am Fam Physician 80(3): 273-9 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
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, ジ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 |
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, ジンドウミャクキョウサクショウ, 腎動脈狭窄症NOS, ジンド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 |
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, ジンドウミャクキンセンイセイケイセイイジョウ, ジンド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 |
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, キョケツセイジンショウ |
Hungarian | Ischaemiás nephropathia, Ischemiás nephropathia |