Wikipedia

Renal artery stenosis

Renal artery stenosis(RAS) is thenarrowingof one or both of therenal arteries,most often caused byatherosclerosisorfibromuscular dysplasia.This narrowing of the renal artery can impedeblood flowto the targetkidney,resulting inrenovascular hypertension– a secondary type ofhigh blood pressure.Possible complications of renal artery stenosis arechronic kidney diseaseandcoronary artery disease.[1]

Renal artery stenosis
SpecialtyNephrology
Risk factorsSmoking, High blood pressure[1]
Diagnostic methodCaptopril challenge test, Doppler ultrasound[2][3]
TreatmentACE inhibitors[1]

Signs and symptoms

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Most cases of renal artery stenosis are asymptomatic, and the main problem is high blood pressure that cannot be controlled with medication.[4]Decreasedkidney functionmay develop if both kidneys do not receive adequate blood flow, furthermore some people with renal artery stenosis present with episodes offlash pulmonary edema.[5]

Cause

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Renal artery stenosis is most often caused by atherosclerosis which causes the renal arteries to harden and narrow due to the build-up ofplaque.This is known as atherosclerotic renovascular disease, which accounts for about 90% of cases.[6]This narrowing of renal arteries due to plaque build-up leads to higher blood pressure within the artery and decreased blood flow to the kidney. This decreased blood flow leads to decreased blood pressure in the kidney, which leads to the activation of the Renin-Angiotensin-Aldosterone (RAA) system. Juxtaglomerular cells secrete renin, which converts angiotensinogen to angiotensin I, which is then converted to angiotensin II by angiotensin converting enzyme (ACE). Angiotensin II then acts on the adrenal cortex to increase secretion of the hormone aldosterone. Aldosterone causes sodium and water retention, leading to an increase in blood volume and blood pressure. Therefore, people with RAS have chronic high blood pressure because their RAA system is hyperactivated.[7]

Pathophysiology

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The pathophysiology of renal artery stenosis leads to changes in the structure of the kidney that are most noticeable in thetubular tissue.[8]

Changes include:[8]

Diagnosis

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Assessment of Kidneys with Renal Artery Stenosis taken by Magnetic Resonance Angiography.

The diagnosis of renal artery stenosis can use many techniques to determine if the condition is present, aclinical prediction ruleis available to guide diagnosis.[9]

Among the diagnostic techniques are:

The specific criteria for renal artery stenosis on Doppler are an acceleration time of greater than 70 milliseconds, an acceleration index of less than 300 cm/sec² and a velocity ratio of the renal artery to aorta of greater than 3.5.[2]

Treatment

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A diuretic (Hydrochlorothiazide)

Atherosclerotic renal artery stenosis

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It is initially treated with medications, includingdiuretics,andmedications for blood pressure control.[8]When high-grade renal artery stenosis is documented and blood pressure cannot be controlled with medication, or if renal function deteriorates,surgerymay be resorted to. The most commonly used procedure is aminimally-invasiveangioplastywith or withoutstenting.It is unclear if this approach yields better results than the use of medications alone.[15]It is a relatively safe procedure.[15]If all else fails and the kidney is thought to be worsening hypertension and revascularization with angioplasty or surgery does not work, then surgical removal of the affected kidney (nephrectomy) may significantly improve high blood pressure.[16]

Fibromuscular dysplasia

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Angioplasty alone is preferred infibromuscular dysplasia,with stenting reserved for unsuccessful angioplasty or complications such asdissection.[17]

References

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  1. ^abc"Renal Artery Stenosis".National Institute of Diabetes and Digestive and Kidney Diseases.Archived fromthe originalon 16 December 2016.Retrieved17 August2015.
  2. ^abcGranata A, Fiorini F, Andrulli S, Logias F, Gallieni M, Romano G, et al. (December 2009)."Doppler ultrasound and renal artery stenosis: An overview".Journal of Ultrasound.12(4): 133–143.doi:10.1016/j.jus.2009.09.006.PMC3567456.PMID23397022.
  3. ^abOng YY (1 January 2005).A Clinical Approach to Medicine.World Scientific.ISBN9789812560735.Archivedfrom the original on 4 September 2024.Retrieved28 October2020.
  4. ^MedlinePlus Encyclopedia:Renovascular hypertension
  5. ^Messerli FH, Bangalore S, Makani H, Rimoldi SF, Allemann Y, White CJ, et al. (2 September 2011)."Flash pulmonary oedema and bilateral renal artery stenosis: the Pickering Syndrome".European Heart Journal.32(18): 2231–2235.doi:10.1093/eurheartj/ehr056.PMID21406441.
  6. ^Vassallo D, Kalra PA (2017)."Atherosclerotic renovascular disease – epidemiology, treatment and current challenges".Advances in Interventional Cardiology.3(3): 191–201.doi:10.5114/aic.2017.70186.PMC5644037.PMID29056991.
  7. ^Safian RD (March 2021). "Renal artery stenosis".Progress in Cardiovascular Diseases.65:60–70.doi:10.1016/j.pcad.2021.03.003.PMID33745915.S2CID232311595.
  8. ^abcRenal Artery StenosisateMedicine
  9. ^Steyerberg E (16 December 2008).Clinical Prediction Models: A Practical Approach to Development, Validation, and Updating.Springer Science & Business Media.ISBN9780387772448.Archivedfrom the original on 4 September 2024.Retrieved28 October2020.
  10. ^Protasiewicz M, Kądziela J, Początek K, Poręba R, Podgórski M, Derkacz A, et al. (November 2013). "Renal Artery Stenosis in Patients With Resistant Hypertension".The American Journal of Cardiology.112(9): 1417–1420.doi:10.1016/j.amjcard.2013.06.030.PMID24135303.
  11. ^Talley NJ, O'Connor S (20 September 2013).Clinical Examination: A Systematic Guide to Physical Diagnosis.Elsevier Health Sciences.ISBN9780729541473.Archivedfrom the original on 4 September 2024.Retrieved28 October2020.
  12. ^Taylor AT (May 2014)."Radionuclides in Nephrourology, Part 2: Pitfalls and Diagnostic Applications".Journal of Nuclear Medicine.55(5): 786–798.doi:10.2967/jnumed.113.133454.PMC4451959.PMID24591488.
  13. ^Sam AH, James T.H. Teo (2010).Rapid Medicine.Wiley-Blackwell.ISBN978-1405183239.
  14. ^Attenberger UI, Morelli JN, Schoenberg SO, Michaely HJ (December 2011)."Assessment of the kidneys: magnetic resonance angiography, perfusion and diffusion".Journal of Cardiovascular Magnetic Resonance.13(1): 70.doi:10.1186/1532-429X-13-70.PMC3228749.PMID22085467.
  15. ^abJenks S, Yeoh SE, Conway BR (5 December 2014)."Balloon angioplasty, with and without stenting, versus medical therapy for hypertensive patients with renal artery stenosis".Cochrane Database of Systematic Reviews.2014(12): CD002944.doi:10.1002/14651858.CD002944.pub2.PMC7138037.PMID25478936.
  16. ^Fine RN, Webber SA, Harmon WE, Kelly D, Olthoff KM (8 April 2009).Pediatric Solid Organ Transplantation.John Wiley & Sons.ISBN9781444312737.Archivedfrom the original on 4 September 2024.Retrieved28 October2020.
  17. ^Chrysant SG, Chrysant GS (February 2014)."Treatment of hypertension in patients with renal artery stenosis due to fibromuscular dysplasia of the renal arteries".Cardiovascular Diagnosis and Therapy.4(1): 36–43.doi:10.3978/j.issn.2223-3652.2014.02.01.PMC3943779.PMID24649423.

Further reading

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Scholiahas atopicprofile forRenal artery stenosis.
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