23 - Clinical Evaluation of Renal Artery Disease

Abstract

Renal artery stenosis (RAS) is a common cause of secondary hypertension. It is important to recognize that there is a difference between hypertension in association with atherosclerotic RAS and hypertension caused by RAS (renovascular hypertension). Incidentally discovered RAS is quite common, whereas atherosclerotic renovascular hypertension occurs much less frequently. In excess of 90% of all renovascular disease is caused by atherosclerosis. Fibromuscular dysplasia (FMD) is the second most common cause of RAS. Patients with atherosclerotic RAS are typically older than age 65 and have the usual risk factors for atherosclerosis. FMD predominately occurs in women (94%) with a mean age at diagnosis of 54 but it may occur at any age. The most common clinical manifestation of FMD is hypertension, whereas atherosclerotic RAS may present with hypertension, acute and chronic kidney disease, and/or recurrent episodes of heart failure and “flash” pulmonary edema. FMD and atherosclerotic RAS may also be an incidental finding when imaging is performed for another reason. In this chapter, we will discuss the clinical clues to suggest the presence of RAS and the various imaging tests used to make this diagnosis.