Management of Renovascular Disease

Abstract

Introduction: Renal artery stenosis (RAS) is not rare, but is often asymptomatic. In older individuals, atherosclerosis is the most common cause of RAS. Atherosclerotic RAS is usually one manifestation of wide spread atherosclerotic disease, and its presence increases the morbidity and mortality of other manifestations of atherosclerotic disease. Review: Renal arterial disease discovered incidentally can be managed expectantly as long as blood pressure and kidney function are well maintained. Revascularization can be considered with the prospect of improving blood pressure control or impaired kidney function, but its outcomes are heterogeneous. The potential for serious deterioration in kidney function after revascularization underscores the need to select patients carefully for vascular procedures in the kidney. Angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are effective in treating most cases of hypertension in atherosclerotic RAS. In addition, clinical data suggest that the survival of patients with renovascular hypertension is better when ACE inhibitors are part of therapy than when they are not. This benefit may be in part due to the fact that ACE inhibitors reduce morbidity and mortality in congestive heart failure which is common co-morbidity in patients with RAS. Withdrawal of the ACE inhibitor in such patients should occur only when the rise in serum creatinine level exceeds 30% above baseline within the first two months of ACE inhibitor initiation, or if hyperkalemia develops. Conclusion: Renovascular hypertension is best managed with ACE inhibitors or ARBs as long as blood pressure and renal function are well maintained. Revascularization should be considered if blood pressure control is not adequate or if renal function deteriorates. Key words: renovascular disease, renal artery stenosis, renal artery occlusion