Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Clinical manifestations and diagnosis of chronic kidney disease resulting from atherosclerotic renal artery stenosis

Stephen Textor, MD
Lionel U Mailloux, MD, FACP
Section Editors
George L Bakris, MD
Norman M Kaplan, MD
Deputy Editor
John P Forman, MD, MSc


Many but not all patients with atherosclerotic renal artery stenosis have chronic kidney disease (CKD) that is primarily due to a reduction in blood flow induced by the stenosis. In general, clinically progressive CKD (marked by an increase in the serum creatinine) occurs when the stenosis threatens the entire renal mass. Hence, patients with CKD resulting from atherosclerotic renal artery stenosis usually have high-grade stenosis of both renal arteries or stenosis to a solitary functioning kidney.

However, renal artery stenosis may be an "incidental" finding in patients who have CKD that is caused by a separate disorder (eg, diabetic nephropathy). It can be difficult to distinguish between patients whose disease is induced by renal artery stenosis and those who have an alternative cause of CKD.

Ischemic nephropathy is discussed in this topic. Determining which hypertensive patients to evaluate for renal artery stenosis, establishing the diagnosis of renal artery stenosis, and treatment of patients with unilateral or bilateral atherosclerotic renal artery stenosis are presented elsewhere. (See "Evaluation of secondary hypertension" and "Establishing the diagnosis of renovascular hypertension" and "Treatment of unilateral atherosclerotic renal artery stenosis" and "Treatment of bilateral atherosclerotic renal artery stenosis or stenosis to a solitary functioning kidney".)

In addition, the diagnosis and treatment of fibromuscular dysplasia are discussed in other topics. (See "Clinical manifestations and diagnosis of fibromuscular dysplasia" and "Treatment of fibromuscular dysplasia of the renal arteries".)


Chronic kidney disease (CKD) that results from atherosclerotic renal artery stenosis is frequently called ischemic nephropathy [1-3]. Broadly speaking, "ischemic nephropathy" can refer to a reduction in glomerular filtration rate (GFR) produced by any cause of diminished renal blood flow. In principle, this could include ischemic acute tubular necrosis, intrarenal arterial or capillary obstruction due to vasculitis, coagulation or hemolytic disorders (such as a thrombotic microangiopathy or sickle cell disease), or immune deposits (as with glomerulonephritis).

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Mar 14, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Textor SC, Misra S, Oderich GS. Percutaneous revascularization for ischemic nephropathy: the past, present, and future. Kidney Int 2013; 83:28.
  2. Adamczak M, Wiecek A. Ischemic nephropathy - pathogenesis and treatment. Nefrologia 2012; 32:432.
  3. Chonchol M, Linas S. Diagnosis and management of ischemic nephropathy. Clin J Am Soc Nephrol 2006; 1:172.
  4. Textor SC, Wilcox CS. Ischemic nephropathy/azotemic renovascular disease. Semin Nephrol 2000; 20:489.
  5. Gloviczki ML, Glockner JF, Lerman LO, et al. Preserved oxygenation despite reduced blood flow in poststenotic kidneys in human atherosclerotic renal artery stenosis. Hypertension 2010; 55:961.
  6. ASTRAL Investigators, Wheatley K, Ives N, et al. Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med 2009; 361:1953.
  7. Cooper CJ, Murphy TP, Cutlip DE, et al. Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med 2014; 370:13.
  8. Textor SC, Novick AC, Tarazi RC, et al. Critical perfusion pressure for renal function in patients with bilateral atherosclerotic renal vascular disease. Ann Intern Med 1985; 102:308.
  9. Imanishi M, Akabane S, Takamiya M, et al. Critical degree of renal arterial stenosis that causes hypertension in dogs. Angiology 1992; 43:833.
  10. Gloviczki ML, Glockner JF, Crane JA, et al. Blood oxygen level-dependent magnetic resonance imaging identifies cortical hypoxia in severe renovascular disease. Hypertension 2011; 58:1066.
  11. Chade AR, Rodriguez-Porcel M, Grande JP, et al. Distinct renal injury in early atherosclerosis and renovascular disease. Circulation 2002; 106:1165.
  12. Herrmann SM, Saad A, Eirin A, et al. Differences in GFR and Tissue Oxygenation, and Interactions between Stenotic and Contralateral Kidneys in Unilateral Atherosclerotic Renovascular Disease. Clin J Am Soc Nephrol 2016; 11:458.
  13. Keddis MT, Garovic VD, Bailey KR, et al. Ischaemic nephropathy secondary to atherosclerotic renal artery stenosis: clinical and histopathological correlates. Nephrol Dial Transplant 2010; 25:3615.
  14. Greco BA, Breyer JA. Atherosclerotic ischemic renal disease. Am J Kidney Dis 1997; 29:167.
  15. Rimmer JM, Gennari FJ. Atherosclerotic renovascular disease and progressive renal failure. Ann Intern Med 1993; 118:712.
  16. Safian RD, Textor SC. Renal-artery stenosis. N Engl J Med 2001; 344:431.
  17. Fatica RA, Port FK, Young EW. Incidence trends and mortality in end-stage renal disease attributed to renovascular disease in the United States. Am J Kidney Dis 2001; 37:1184.
  18. Valderrábano F, Berthoux FC, Jones EH, Mehls O. Report on management of renal failure in Europe, XXV, 1994 end stage renal disease and dialysis report. The EDTA-ERA Registry. European Dialysis and Transplant Association-European Renal Association. Nephrol Dial Transplant 1996; 11 Suppl 1:2.
  19. Korsakas S, Mohaupt MG, Dinkel HP, et al. Delay of dialysis in end-stage renal failure: prospective study on percutaneous renal artery interventions. Kidney Int 2004; 65:251.
  20. Textor SC, Wilcox CS. Renal artery stenosis: a common, treatable cause of renal failure? Annu Rev Med 2001; 52:421.
  21. Scoble JE, Hamilton G. Atherosclerotic renovascular disease. BMJ 1990; 300:1670.
  22. Appel RG, Bleyer AJ, Reavis S, Hansen KJ. Renovascular disease in older patients beginning renal replacement therapy. Kidney Int 1995; 48:171.
  23. Mailloux LU, Napolitano B, Bellucci AG, et al. Renal vascular disease causing end-stage renal disease, incidence, clinical correlates, and outcomes: a 20-year clinical experience. Am J Kidney Dis 1994; 24:622.
  24. van Ampting JM, Penne EL, Beek FJ, et al. Prevalence of atherosclerotic renal artery stenosis in patients starting dialysis. Nephrol Dial Transplant 2003; 18:1147.
  25. Leertouwer TC, Pattynama PM, van den Berg-Huysmans A. Incidental renal artery stenosis in peripheral vascular disease: a case for treatment? Kidney Int 2001; 59:1480.
  26. Baboolal K, Evans C, Moore RH. Incidence of end-stage renal disease in medically treated patients with severe bilateral atherosclerotic renovascular disease. Am J Kidney Dis 1998; 31:971.
  27. Bax L, Woittiez AJ, Kouwenberg HJ, et al. Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function: a randomized trial. Ann Intern Med 2009; 150:840.
  28. Oskin TC, Hansen KJ, Deitch JS, et al. Chronic renal artery occlusion: nephrectomy versus revascularization. J Vasc Surg 1999; 29:140.
  29. Sivamurthy N, Surowiec SM, Culakova E, et al. Divergent outcomes after percutaneous therapy for symptomatic renal artery stenosis. J Vasc Surg 2004; 39:565.
  30. Ritchie J, Green D, Chrysochou C, et al. High-risk clinical presentations in atherosclerotic renovascular disease: prognosis and response to renal artery revascularization. Am J Kidney Dis 2014; 63:186.
  31. Kalra PA, Chrysochou C, Green D, et al. The benefit of renal artery stenting in patients with atheromatous renovascular disease and advanced chronic kidney disease. Catheter Cardiovasc Interv 2010; 75:1.
  32. Textor SC. Attending rounds: a patient with accelerated hypertension and an atrophic kidney. Clin J Am Soc Nephrol 2014; 9:1117.
  33. Hadj-Abdelkader M, Alphonse JC, Ravel A, et al. [Proposal of a clinical prediction score for atheromatous renal artery stenosis]. Arch Mal Coeur Vaiss 2003; 96:784.
  34. Madder RD, Hickman L, Crimmins GM, et al. Validity of estimated glomerular filtration rates for assessment of baseline and serial renal function in patients with atherosclerotic renal artery stenosis: implications for clinical trials of renal revascularization. Circ Cardiovasc Interv 2011; 4:219.
  35. Rognant N, Rouvière O, Janier M, et al. Hemodynamic responses to acute and gradual renal artery stenosis in pigs. Am J Hypertens 2010; 23:1216.
  36. MAY AG, DE WEESE JA, ROB CG. Hemodynamic effects of arterial stenosis. Surgery 1963; 53:513.
  37. Drieghe B, Madaric J, Sarno G, et al. Assessment of renal artery stenosis: side-by-side comparison of angiography and duplex ultrasound with pressure gradient measurements. Eur Heart J 2008; 29:517.
  38. De Bruyne B, Manoharan G, Pijls NH, et al. Assessment of renal artery stenosis severity by pressure gradient measurements. J Am Coll Cardiol 2006; 48:1851.
  39. Radermacher J, Ellis S, Haller H. Renal resistance index and progression of renal disease. Hypertension 2002; 39:699.
  40. Herrmann SM, Textor SC. Diagnostic criteria for renovascular disease: where are we now? Nephrol Dial Transplant 2012; 27:2657.
  41. Muray S, Martín M, Amoedo ML, et al. Rapid decline in renal function reflects reversibility and predicts the outcome after angioplasty in renal artery stenosis. Am J Kidney Dis 2002; 39:60.
  42. Novick AC. Patient selection for intervention to preserve renal function in ischemic renal disease. In: Renal Vascular Disease, Novick AC, Scoble J, Hamilton G (Eds), W.B. Saunders Co, LTD, London 1996. p.323.
  43. Krishnamurthi V, Novick AC, Myles JL. Atheroembolic renal disease: effect on morbidity and survival after revascularization for atherosclerotic renal artery stenosis. J Urol 1999; 161:1093.
  44. Cheung CM, Shurrab AE, Buckley DL, et al. MR-derived renal morphology and renal function in patients with atherosclerotic renovascular disease. Kidney Int 2006; 69:715.
  45. Safian RD, Madder RD. Refining the approach to renal artery revascularization. JACC Cardiovasc Interv 2009; 2:161.