Treatment of unilateral atherosclerotic renal artery stenosis
- 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 main vessels to 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.
The treatment of unilateral atherosclerotic renal artery stenosis will be reviewed here. Clinical clues suggesting the presence of renovascular hypertension and establishing the diagnosis of renal artery stenosis, treatment of bilateral 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 bilateral atherosclerotic renal artery stenosis or stenosis to a solitary functioning kidney" 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".)
BRIEF 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 three prospective treatment trials of patients with renal artery stenosis, the prevalence of unilateral disease (compared with bilateral disease) ranged from 53 to 80 percent [2-4]. Most patients with unilateral renal artery stenosis can be managed with antihypertensive drug therapy.
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- BRIEF 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
- Progression of stenosis
- Impaired renal function with angiotensin inhibition
- Loss of functional renal mass in the stenotic kidney
- - Percutaneous transluminal renal angioplasty
- Stent placement
- Procedural complications
- Split kidney function
- - Surgery
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS