Renal artery stenosis resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Karol Gema Hernandez, M.D. [2]

Overview

Renal artery stenosis is defined as a dimished diameter of the lumen of the renal artery. Renal artery of >70% is considered hemodynamically significant.[1]

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Renal artery stenosis does not have life threatening causes.

Common Causes

Management

Diagnostic Approach

Shown below is the diagnostic approach to RAS based on the 2013 AHA Guidelines Recommendations for Management of Patients with PAD.[1]

 
 
 
 
Determine if one or more of the following is present:
❑ Onset of hypertension before the age of 30 years
❑ Onset of severe hypertension after the age of 55
❑ Accelerated, resistant, or malignant hypertension
❑ Development of new azotemia or worsening renal function after administration of an ACE inhibitor or ARB agent
❑ Unexplained atrophic kidney or size discrepancy between kidneys >1.5 cm
❑ Sudden, unexplained pulmonary edema
❑ Unexplained renal dysfunction, including individuals starting renal replacement therapy
❑ Multi-vessel CAD
❑ Unexplained CHF
❑ Refractory angina
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Proceed with non-invasive imaging [2]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the patient allergic to contrast?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient has any of the following?
❑ Implanted devices:
- Pacemakers
- Defibrillators
- Cochlear implants
- Spinal cord stimulators
Claustrophobia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Proceed with US
 
❑ Proceed with MRA
 
❑ Proceed with CT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inconclusive noninvasive test but with high clinical index of suspicion:
❑ Perform catheter angiography
 
Confirmed RAS:
❑ Proceed to treatment
 
 
 
 
 


Therapeutic Approach

Shown below is the diagnostic approach to RAS based on the 2013 AHA Guidelines Recommendations for Management of Patients with PAD.[1]

 
 
Initiate a regimen that combines:[3]
❑ Tight blood pressure control to <130/80 mmHg (120/75 mmHg if proteinuria is present) with:

ACEI, or
ARB, or
CCB, or
Beta blockers
❑ Control of hyperlipidemia (LDL cholesterol <70 mg/dl) with statins
❑ Glycemic control (hemoglobin A1c <7%)
Antiplatelet agents
❑ Life style modifications:
♦ Smoking cessation counseling

♦ Normalization of body weight
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed to evaluate clinical indications for revascularization
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient has any of the following?
❑ RAS with:

- Accelerated, resistant, or malignant hypertension
- Hypertension with an unexplained unilateral small kidney

- Hypertension with medication intolerance
❑ Progressive CKD with bilateral RAS or RAS to a solitary functioning kidney
❑ Hemodynamically significant RAS with recurrent, unexplainedCHF or sudden, unexplained pulmonary edema
Unstable angina
❑ Asymptomatic bilateral or solitary viable kidney
Chronic renal failure with unilateral RAS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If any of the above AND:
 
If any of the above AND:
❑ Complex fibromuscular dysplasia disease that extends into segmental arteries, OR
Macroaneurysms, OR
Atherosclerotic RAS with multiple small renal arteries or early primary branching of the main renal artery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Endovascular treatment
 
Renal artery surgery

References

  1. 1.0 1.1 1.2 Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH; et al. (2013). "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.". Circulation. 127 (13): 1425–43. PMID 23457117. doi:10.1161/CIR.0b013e31828b82aa. 
  2. Lao D, Parasher PS, Cho KC, Yeghiazarians Y (2011). "Atherosclerotic renal artery stenosis--diagnosis and treatment.". Mayo Clin Proc. 86 (7): 649–57. PMC 3127560Freely accessible. PMID 21719621‎ . doi:10.4065/mcp.2011.0181. 
  3. Annigeri RA (2012). "Medical therapy is best for atherosclerotic renal artery stenosis: Arguments for.". Indian J Nephrol. 22 (1): 1–4. PMC 3263056Freely accessible. PMID 22279335. doi:10.4103/0971-4065.91177. 



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