Treatment of bilateral atherosclerotic renal artery stenosis or stenosis to a solitary functioning kidney
- Stephen Textor, MD
Stephen Textor, MD
- Professor of Medicine
- Division of Nephrology and Hypertension
- Mayo Clinic College of Medicine
- Rochester, Minnesota
- Section Editors
- George L Bakris, MD
George L Bakris, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Professor of Medicine
- The University of Chicago
- Norman M Kaplan, MD
Norman M Kaplan, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Clinical Professor of Internal Medicine
- University of Texas Southwestern Medical Center
Renal artery stenosis is a relatively common finding in older patients with hypertension. However, renal artery stenosis is the primary cause of hypertension (ie, renovascular hypertension) only in certain settings.
In most cases of renal artery stenosis, one kidney is affected with the second kidney being essentially normal, hence the designation "unilateral" disease. Individuals with high-grade stenosis to both kidneys, or to a solitary functioning kidney thereby affecting the entire functioning renal mass, are considered to have "bilateral" disease. Bilateral renal artery stenosis, or stenosis to a solitary functioning kidney, merits specific consideration because of its additional contribution to fluid retention, loss of kidney function, and congestive heart failure.
The treatment of bilateral atherosclerotic renal artery stenosis (or stenosis of a solitary functioning kidney) will be reviewed here. Clinical clues suggesting the presence of renovascular hypertension and establishing the diagnosis of renal artery stenosis, treatment of unilateral atherosclerotic renal artery stenosis, issues related to chronic kidney disease associated with atherosclerotic renovascular disease, and diagnosis and treatment of fibromuscular disease are presented in detail elsewhere. (See "Evaluation of secondary hypertension" and "Establishing the diagnosis of renovascular hypertension" and "Treatment of unilateral atherosclerotic renal artery stenosis" and "Clinical manifestations and diagnosis of chronic kidney disease resulting from atherosclerotic renal artery stenosis" and "Clinical manifestations and diagnosis of fibromuscular dysplasia" and "Treatment of fibromuscular dysplasia of the renal arteries".)
REVIEW OF PRESENTATION AND DIAGNOSIS
Epidemiology — The prevalence of renovascular hypertension is probably less than 1 percent in patients with mild hypertension but may be as high as 10 to 40 percent in patients with acute (even if superimposed on a preexisting elevation in blood pressure), severe, or refractory hypertension . (See "Evaluation of secondary hypertension", section on 'Clinical clues for renovascular hypertension'.)
In prospective treatment trials of patients with renal artery stenosis, the prevalence of bilateral disease (rather than unilateral disease) ranged from 23 to 54 percent [2-4]. Rarely are both arteries affected with stenosis to an identical degree.
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- REVIEW OF PRESENTATION AND DIAGNOSIS
- Clinical clues
- RISK FACTOR REDUCTION
- General approach to therapy
- Revascularization versus medical therapy alone
- Overview of therapeutic options
- - Medical therapy
- - Percutaneous transluminal renal angioplasty and stenting
- Stent placement
- Procedural complications
- - Surgery
- In-hospital mortality
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS