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Diagnosis and treatment of renal artery stenosis

Nature Reviews Nephrology volume 6, pages 151–159 (2010)Cite this article

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Abstract

A reduction in the diameter of the renal arteries can lead to hypertension, renal dysfunction and/or pulmonary edema. About 90% of patients with renal artery stenosis have atherosclerosis, and 10% have fibromuscular dysplasia. Atherosclerotic renal artery stenosis is a common condition that typically occurs in patients at high risk of cardiovascular disease with coexistent vascular disease at nonrenal sites. Patients who undergo revascularization to treat hypertension associated with atherosclerotic stenosis need to continue medication with statins, antiplatelet agents and renin–angiotensin antagonists after the procedure to prevent renal and cardiovascular events. Two recent trials compared renal outcomes in patients with atherosclerotic stenosis who were treated with antihypertensive medication plus stenting with those in patients who were treated with medication alone. Available results favor a conservative approach (medication only) for most patients with atherosclerotic renal artery stenosis. These results, however, concern patients with stable clinical conditions and, in many cases, only moderate renal artery lesions. Blood pressure outcome after angioplasty is more favorable in patients with fibromuscular renal artery disease, who usually do not have renal failure, than in those with atherosclerosis.

Key Points

  • Atherosclerotic renovascular disease is a cardiovascular condition that is associated with renal artery stenosis (RAS); treatment with statins and renin–angiotensin antagonists can provide cardiovascular protection

  • Renal impairment associated with atherosclerotic RAS is both a marker and a risk factor for cardiovascular disease

  • Patients with atherosclerotic RAS and a stable condition should be treated first with medication

  • Renal artery stenting is not recommended for most patients with atherosclerotic RAS, but it might be beneficial for those with refractory hypertension or rapidly progressing renal or cardiac dysfunction

  • Patients with fibromuscular dysplasia of the renal artery usually have renovascular hypertension without renal failure or associated vascular disease

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Figure 1: Incidence (per 100 patient-years) of cardiovascular events, death and renal replacement therapy among Medicare patients aged 67 years or older, with or without ARVD.
Figure 2: Effect of treatment with renin–angiotensin antagonists on cardiovascular and renal outcomes in patients with atherosclerotic renal artery stenosis.
Figure 3: The 'string-of-beads' characteristic of medial fibromuscular dysplasia on angiography.

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Acknowledgements

The authors would like to thank Philip Kalra for critical reading of the manuscript.

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Authors and Affiliations

  1. Université Paris Descartes, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Hypertension Unit, 20 rue Leblanc, Paris Cedex 15, 75908, France

    Pierre-François Plouin

  2. Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, 3584, CX, The Netherlands

    Liesbeth Bax

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Correspondence to Pierre-François Plouin.

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Plouin, PF., Bax, L. Diagnosis and treatment of renal artery stenosis. Nat Rev Nephrol 6, 151–159 (2010). https://doi.org/10.1038/nrneph.2009.230

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