Establishing the diagnosis of renovascular hypertension
- 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
Renovascular disease is an important, potentially correctable cause of secondary hypertension. The frequency with which it occurs is variable. It accounts for less than 1 percent of cases of mild to moderate elevations in blood pressure . By contrast, the prevalence is much higher in patients with acute (even if superimposed upon a preexisting elevation in blood pressure), severe, or refractory hypertension .
The indications for testing, methods of testing, and interpretation of diagnostic tests for renovascular disease will be reviewed here. The clinical features and clues to a diagnosis of renovascular hypertension, as well as the treatment of renovascular hypertension and ischemic nephropathy, are presented elsewhere. (See "Evaluation of secondary hypertension", section on 'Clinical clues for 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" and "Treatment of fibromuscular dysplasia of the renal arteries" and "Clinical manifestations and diagnosis of chronic kidney disease resulting from atherosclerotic renal artery stenosis".)
INDICATIONS FOR TESTING
Testing for renovascular disease is warranted in patients who fulfill all of the following criteria :
●The clinical findings suggest a cause of secondary hypertension rather than primary hypertension (formerly called "essential" hypertension).
●The patient does not appear to have another cause of secondary hypertension such as primary kidney disease, primary aldosteronism, or pheochromocytoma. (See "Evaluation of secondary hypertension", section on 'Clues for other major forms of secondary hypertension'.)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:
- Dworkin LD, Cooper CJ. Clinical practice. Renal-artery stenosis. N Engl J Med 2009; 361:1972.
- Textor SC, Lerman L. Renovascular hypertension and ischemic nephropathy. Am J Hypertens 2010; 23:1159.
- Ronden RA, Houben AJ, Kessels AG, et al. Predictors of clinical outcome after stent placement in atherosclerotic renal artery stenosis: a systematic review and meta-analysis of prospective studies. J Hypertens 2010; 28:2370.
- Hughes JS, Dove HG, Gifford RW Jr, Feinstein AR. Duration of blood pressure elevation in accurately predicting surgical cure of renovascular hypertension. Am Heart J 1981; 101:408.
- White CJ, Jaff MR, Haskal ZJ, et al. Indications for renal arteriography at the time of coronary arteriography: a science advisory from the American Heart Association Committee on Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology, and the Councils on Cardiovascular Radiology and Intervention and on Kidney in Cardiovascular Disease. Circulation 2006; 114:1892.
- Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 2006; 113:e463.
- Williams GJ, Macaskill P, Chan SF, et al. Comparative accuracy of renal duplex sonographic parameters in the diagnosis of renal artery stenosis: paired and unpaired analysis. AJR Am J Roentgenol 2007; 188:798.
- Radermacher J, Chavan A, Bleck J, et al. Use of Doppler ultrasonography to predict the outcome of therapy for renal-artery stenosis. N Engl J Med 2001; 344:410.
- Ikee R, Kobayashi S, Hemmi N, et al. Correlation between the resistive index by Doppler ultrasound and kidney function and histology. Am J Kidney Dis 2005; 46:603.
- Santos S, Leite LR, Tse TS, et al. [Renal resistance index predicting outcome of renal revascularization for renovascular hypertension]. Arq Bras Cardiol 2010; 94:452.
- Krumme B, Hollenbeck M. Doppler sonography in renal artery stenosis--does the Resistive Index predict the success of intervention? Nephrol Dial Transplant 2007; 22:692.
- Crutchley TA, Pearce JD, Craven TE, et al. Clinical utility of the resistive index in atherosclerotic renovascular disease. J Vasc Surg 2009; 49:148.
- Zeller T, Müller C, Frank U, et al. Stent angioplasty of severe atherosclerotic ostial renal artery stenosis in patients with diabetes mellitus and nephrosclerosis. Catheter Cardiovasc Interv 2003; 58:510.
- Echevarría JJ, Miguélez JL, López-Romero S, et al. [Arteriographic correlation in 30 patients with renal vascular disease diagnosed with multislice CT]. Radiologia 2008; 50:393.
- Glockner JF, Vrtiska TJ. Renal MR and CT angiography: current concepts. Abdom Imaging 2007; 32:407.
- Olbricht CJ, Paul K, Prokop M, et al. Minimally invasive diagnosis of renal artery stenosis by spiral computed tomography angiography. Kidney Int 1995; 48:1332.
- Vasbinder GB, Nelemans PJ, Kessels AG, et al. Accuracy of computed tomographic angiography and magnetic resonance angiography for diagnosing renal artery stenosis. Ann Intern Med 2004; 141:674.
- Postma CT, Joosten FB, Rosenbusch G, Thien T. Magnetic resonance angiography has a high reliability in the detection of renal artery stenosis. Am J Hypertens 1997; 10:957.
- Rieumont MJ, Kaufman JA, Geller SC, et al. Evaluation of renal artery stenosis with dynamic gadolinium-enhanced MR angiography. AJR Am J Roentgenol 1997; 169:39.
- Schoenberg SO, Rieger J, Johannson LO, et al. Diagnosis of renal artery stenosis with magnetic resonance angiography: update 2003. Nephrol Dial Transplant 2003; 18:1252.
- Schoenberg SO, Knopp MV, Londy F, et al. Morphologic and functional magnetic resonance imaging of renal artery stenosis: a multireader tricenter study. J Am Soc Nephrol 2002; 13:158.
- Textor SC. Pitfalls in imaging for renal artery stenosis. Ann Intern Med 2004; 141:730.
- Thornton MJ, Thornton F, O'Callaghan J, et al. Evaluation of dynamic gadolinium-enhanced breath-hold MR angiography in the diagnosis of renal artery stenosis. AJR Am J Roentgenol 1999; 173:1279.
- Slovut DP, Olin JW. Fibromuscular dysplasia. N Engl J Med 2004; 350:1862.
- Wilcox CS. Use of angiotensin-converting-enzyme inhibitors for diagnosing renovascular hypertension. Kidney Int 1993; 44:1379.
- Lerman LO, Nath KA, Rodriguez-Porcel M, et al. Increased oxidative stress in experimental renovascular hypertension. Hypertension 2001; 37:541.
- Textor SC. Chapter 47: Renovascular Hypertension and Ischemic Nephropathy. In: Brenner and Rector's: The Kidney, 9th Ed, Elsevier, Philadelphia 2012. p.1752.
- Svetkey LP, Kadir S, Dunnick NR, et al. Similar prevalence of renovascular hypertension in selected blacks and whites. Hypertension 1991; 17:678.
- Derkx FH, Schalekamp MA. Renal artery stenosis and hypertension. Lancet 1994; 344:237.
- Pedersen EB. Angiotensin-converting enzyme inhibitor renography. Pathophysiological, diagnostic and therapeutic aspects in renal artery stenosis. Nephrol Dial Transplant 1994; 9:482.
- Setaro JF, Saddler MC, Chen CC, et al. Simplified captopril renography in diagnosis and treatment of renal artery stenosis. Hypertension 1991; 18:289.
- Mann SJ, Pickering TG. Detection of renovascular hypertension. State of the art: 1992. Ann Intern Med 1992; 117:845.
- van Jaarsveld BC, Krijnen P, Derkx FH, et al. The place of renal scintigraphy in the diagnosis of renal artery stenosis. Fifteen years of clinical experience. Arch Intern Med 1997; 157:1226.
- Krijnen P, van Jaarsveld BC, Deinum J, et al. Which patients with hypertension and atherosclerotic renal artery stenosis benefit from immediate intervention? J Hum Hypertens 2004; 18:91.
- van Onna M, Houben AJ, Kroon AA, et al. Asymmetry of renal blood flow in patients with moderate to severe hypertension. Hypertension 2003; 41:108.
- Kane GC, Textor SC, Schirger A, Garovic VD. Revisiting the role of nephrectomy for advanced renovascular disease. Am J Med 2003; 114:729.
- Roubidoux MA, Dunnick NR, Klotman PE, et al. Renal vein renins: inability to predict response to revascularization in patients with hypertension. Radiology 1991; 178:819.
- Vaughan ED Jr. Curable renal hypertension: renin, marker or cause? Question answered. Am J Hypertens 2014; 27:1000.
- Strong CG, Hunt JC, Sheps SG, et al. Renal venous renin activity. Enhancement of sensitivity of lateralization by sodium depletion. Am J Cardiol 1971; 27:602.
- Rossi GP, Cesari M, Chiesura-Corona M, et al. Renal vein renin measurements accurately identify renovascular hypertension caused by total occlusion of the renal artery. J Hypertens 2002; 20:975.
- Pedersen EB. New tools in diagnosing renal artery stenosis. Kidney Int 2000; 57:2657.
- Elkohen M, Beregi JP, Deklunder G, et al. A prospective study of helical computed tomography angiography versus angiography for the detection of renal artery stenoses in hypertensive patients. J Hypertens 1996; 14:525.
- Garovic VD, Textor SC. Renovascular hypertension and ischemic nephropathy. Circulation 2005; 112:1362.
- Scolari F, Ravani P. Atheroembolic renal disease. Lancet 2010; 375:1650.
- Chi YW, White CJ, Thornton S, Milani RV. Ultrasound velocity criteria for renal in-stent restenosis. J Vasc Surg 2009; 50:119.
- 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.
- 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.
- Choudhri AH, Cleland JG, Rowlands PC, et al. Unsuspected renal artery stenosis in peripheral vascular disease. BMJ 1990; 301:1197.
- Marcantoni C, Zanoli L, Rastelli S, et al. Effect of renal artery stenting on left ventricular mass: a randomized clinical trial. Am J Kidney Dis 2012; 60:39.
- INDICATIONS FOR TESTING
- DIAGNOSTIC TEST OPTIONS
- Testing options
- Duplex Doppler ultrasonography
- - Resistive index
- Spiral CT scan with CT angiography
- Magnetic resonance angiography
- Noninvasive imaging is less reliable in fibromuscular dysplasia
- Tests of limited utility, but occasionally performed
- - Plasma renin activity
- - Captopril renogram
- - Renal vein renin measurements
- SELECTING A DIAGNOSTIC TEST
- Patients without renal insufficiency
- Patients with renal insufficiency
- INTERPRETING THE RESULTS OF DIAGNOSTIC TESTS
- Incidental lesions
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS