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Renal artery stenosis

Last updated: September 23, 2021

Summarytoggle arrow icon

Renal artery stenosis is the narrowing of one or both renal arteries. It is most commonly caused by atherosclerosis. In young women, fibromuscular dysplasia is an important underlying cause. Decreased renal blood flow due to renal artery stenosis causes activation of the renin-angiotensin-aldosterone system, which in turn results in secondary hypertension. Physical examination may reveal an abdominal bruit. Patients with progressive renal artery stenosis may develop renal insufficiency and renal atrophy. Duplex ultrasonography and/or angiography are used for screening and to confirm the diagnosis. Treatment of renal artery stenosis primarily consists of antihypertensive therapy, including ACE inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers, or beta blockers. Antihypertensive therapy may need to be continued indefinitely. Patients on ACE inhibitors or ARBs should be closely monitored for an increase in serum creatinine, especially if they have bilateral renal artery stenosis. Patients with hemodynamically significant renal artery stenosis may require revascularization. Treatment of the underlying cause is essential to prevent disease progression.

  • Accounts for 1–10% of all hypertension cases [1]
  • 3–10% of pediatric cases of secondary hypertension have a renovascular etiology. [2]
  • Age and sex preponderance depend on the underlying cause (see “Etiology” below).

Epidemiological data refers to the US, unless otherwise specified.

Imaging is required to confirm a clinical suspicion of renal artery stenosis. Laboratory findings may provide supportive evidence but are not diagnostic.

Imaging [8][10]

Indications

A high pretest probability for renal artery stenosis, as determined by the presence of ≥ 1 of the following features. [8]

Modalities [8][10][11]

The choice of modality depends on the presence and severity of renal dysfunction. Consider a nephrology and/or radiology consult in patients with significant renal dysfunction (eGFR < 30 mL/min/1.73 m2) to help guide this decision.

In patients with renal dysfunction, there is a risk of contrast-induced nephropathy with CT/catheter angiography and a risk of nephrogenic systemic fibrosis with MR angiography with gadolinium contrast.

Findings

  • Increased systolic flow velocity in the renal artery (on duplex US) [10]
  • Segmental narrowing of one or both renal arteries
    • Stenotic segment(s) can be complete or partial and solitary or multiple.
    • Hemodynamically significant renal artery stenosis [13][14]
  • The site of renal artery stenosis differs according to the underlying etiology.
  • Ipsilateral renal atrophy (decrease in kidney size) [15]

Patients with hemodynamically significant renal artery stenosis may require revascularization procedures to control hypertension.

Laboratory studies

The differential diagnoses listed here are not exhaustive.

Renal infarction refers to the acute loss of blood supply to the renal parenchyma resulting in necrosis and loss of kidney function.

Etiology

Renal infarction is usually caused by thromboemboli or in situ thrombosis with any of the following etiologies:

Clinical features

Diagnostics

Diagnosis is based on the presence of clinical features. Imaging confirms the diagnosis.

Differential diagnoses

Treatment

References: [19][20]

Approach [8][14][15][21][22]

Medical therapy

All patients with symptomatic or asymptomatic renal artery stenosis should be initiated on medical therapy to control HTN and treat the underlying disease.

Treatment of associated hypertension [8][11][23]

Closely monitor serum creatinine and K+ after initiating ACE inhibitors or ARBs, especially in patients with bilateral renal artery stenosis. Onset or rapid worsening of renal dysfunction can often be reversed by promptly discontinuing the agent.

Treatment of atherosclerosis [15][21]

Revascularization procedures [8][13][14]

General principles

  • Not routinely recommended for patients with well-controlled HTN on optimal medical therapy [26]
  • Only of moderate benefit in patients with fibromuscular dysplasia and of uncertain benefit in patients with atherosclerotic renal artery stenosis [14][27]
  • Unlikely to be beneficial in patients with small, nonviable kidneys [14]
  • Should be reserved primarily for patients with poor response to optimal medical therapy or those with severe bilateral disease or stenosis affecting a solitary functioning kidney

Indications [13][14]

Options [11][27][28]

Further management [14]

  • Dose reduction of antihypertensive agent(s) as required
  • Serial postprocedural duplex US to monitor response to therapy and identify restenosis
  1. Decoste R, Himmelman JG, Grantmyre J. Acute renal infarct without apparent cause: A case report and review of the literature. Canadian Urological Association Journal. 2015; 9 (3-4): p.237. doi: 10.5489/cuaj.2466 . | Open in Read by QxMD
  2. Saeed K. Renal infarction. International Journal of Nephrology and Renovascular Disease. 2012 : p.119. doi: 10.2147/ijnrd.s33768 . | Open in Read by QxMD
  3. McLaughlin K. ABC of arterial and venous disease: Renal artery stenosis. BMJ. 2000; 320 (7242): p.1124-1127. doi: 10.1136/bmj.320.7242.1124 . | Open in Read by QxMD
  4. Zhou XJJ, Laszik ZG, Nadasdy T, D'Agati VD. Silva's Diagnostic Renal Pathology. Cambridge University Press ; 2017
  5. Juxtaglomerular Apparatus Hyperplasia. https://www.arkanalabs.com/jga-hyperplasia/. Updated: May 17, 2017. Accessed: April 16, 2018.
  6. Colvin RB, Chang A. Diagnostic Pathology: Kidney Diseases. Elsevier Health Sciences ; 2015
  7. Renal Artery Stenosis and Occlusion. http://www.merckmanuals.com/professional/genitourinary-disorders/renovascular-disorders/renal-artery-stenosis-and-occlusion. Updated: July 1, 2016. Accessed: February 20, 2017.
  8. Bokhari MR, Bokhari SRA. Renal Artery Stenosis. StatPearls. 2020 .
  9. Chung H, Lee JH, Park E, et al. Long-Term Outcomes of Pediatric Renovascular Hypertension. Kidney and Blood Pressure Research. 2017; 42 (3): p.617-627. doi: 10.1159/000481549 . | Open in Read by QxMD
  10. Anderson JL, Halperin JL, Albert N, et al. Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2013; 61 (14): p.1555-1570. doi: 10.1016/j.jacc.2013.01.004 . | Open in Read by QxMD
  11. Olin JW. Clinical manifestations and diagnosis of fibromuscular dysplasia. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-fibromuscular-dysplasia.Last updated: June 3, 2015. Accessed: February 14, 2017.
  12. American College of Radiology ACR Appropriateness Criteria - Renovascular Hypertension. https://acsearch.acr.org/docs/69374/Narrative/. Updated: January 1, 2017. Accessed: March 1, 2018.
  13. Dworkin LD, Cooper CJ. Renal-Artery Stenosis. N Engl J Med. 2009; 361 (20): p.1972-1978. doi: 10.1056/nejmcp0809200 . | Open in Read by QxMD
  14. Parikh SA, Shishehbor MH, Gray BH, White CJ, Jaff MR. SCAI expert consensus statement for renal artery stenting appropriate use. Catheterization and Cardiovascular Interventions. 2014; 84 (7): p.1163-1171. doi: 10.1002/ccd.25559 . | Open in Read by QxMD
  15. Klein AJ, Jaff MR, Gray BH, et al. SCAI appropriate use criteria for peripheral arterial interventions: An update. Catheter Cardiovasc Interv. 2017; 90 (4): p.E90-E110. doi: 10.1002/ccd.27141 . | Open in Read by QxMD
  16. Bailey SR, Beckman JA, Dao TD, et al. ACC/AHA/SCAI/SIR/SVM 2018 Appropriate Use Criteria for Peripheral Artery Intervention. J Am Coll Cardiol. 2019; 73 (2): p.214-237. doi: 10.1016/j.jacc.2018.10.002 . | Open in Read by QxMD
  17. Lao D, Parasher PS, Cho KC, Yeghiazarians Y. Atherosclerotic Renal Artery Stenosis—Diagnosis and Treatment. Mayo Clinic Proceedings. 2011; 86 (7): p.649-657. doi: 10.4065/mcp.2011.0181 . | Open in Read by QxMD
  18. Olin JW, Gornik HL, Bacharach JM, et al. Fibromuscular Dysplasia: State of the Science and Critical Unanswered Questions. Circulation. 2014; 129 (9): p.1048-1078. doi: 10.1161/01.cir.0000442577.96802.8c . | Open in Read by QxMD
  19. Ruby ST. Unilateral Renal Artery Stenosis Seen Initially as Severe and Symptomatic Hypokalemia. Arch Surg. 1993; 128 (3): p.346-8. doi: 10.1001/archsurg.1993.01420150106019 . | Open in Read by QxMD
  20. Singh PK, Rajput R, Banerjee S, Garg K. Unilateral renal artery stenosis presenting as acute flaccid paralysis: a rare presentation. BMJ Case Reports. 2018 : p.bcr-2018-225889. doi: 10.1136/bcr-2018-225889 . | Open in Read by QxMD
  21. Whelton, PK, Carey, RM et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension. 2017; 71 (6): p.e13–e115. doi: 10.1161/hyp.0000000000000065 . | Open in Read by QxMD
  22. Cooper CJ, Murphy TP, Cutlip DE, et al. Stenting and Medical Therapy for Atherosclerotic Renal-Artery Stenosis. N Engl J Med. 2014; 370 (1): p.13-22. doi: 10.1056/nejmoa1310753 . | Open in Read by QxMD
  23. Vagaonescu TD, Dangas G. Renal Artery Stenosis: Diagnosis and Management. The Journal of Clinical Hypertension. 2002; 4 (5): p.363-370. doi: 10.1111/j.1524-6175.2002.01455.x . | Open in Read by QxMD
  24. Garovic VD, Textor SC. Renovascular Hypertension and Ischemic Nephropathy. Circulation. 2005; 112 (9): p.1362-1374. doi: 10.1161/circulationaha.104.492348 . | Open in Read by QxMD
  25. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary. J Am Coll Cardiol. 2019; 73 (24): p.3168-3209. doi: 10.1016/j.jacc.2018.11.002 . | Open in Read by QxMD
  26. ASTRAL Investigators. Revascularization versus Medical Therapy for Renal-Artery Stenosis. N Engl J Med. 2009; 361 (20): p.1953-1962. doi: 10.1056/nejmoa0905368 . | Open in Read by QxMD
  27. Trinquart L, Mounier-Vehier C, Sapoval M, Gagnon N, Plouin P-F. Efficacy of Revascularization For Renal Artery Stenosis Caused by Fibromuscular Dysplasia. Hypertension. 2010; 56 (3): p.525-532. doi: 10.1161/hypertensionaha.110.152918 . | Open in Read by QxMD
  28. Prince M, Tafur JD, White CJ. When and How Should We Revascularize Patients With Atherosclerotic Renal Artery Stenosis?. JACC Cardiovasc Interv. 2019; 12 (6): p.505-517. doi: 10.1016/j.jcin.2018.10.023 . | Open in Read by QxMD
  29. Textor S. Treatment of Unilateral Atherosclerotic Renal Artery Stenosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/treatment-of-unilateral-atherosclerotic-renal-artery-stenosis.Last updated: June 13, 2017. Accessed: November 25, 2018.