Renal artery stenosis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Shivam Singla, M.D.[2]

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Overview

Patients with Renal artery stenosis require the widespread use of intensive medical therapy. The drugs responsible for the management of renal artery stenosis are ACE inhibitors or ARB's. These drugs inhibit the sympathetic and renin-angiotensin system resulting in controlling hypertension. In patients with bilateral renal artery stenosis, there is an associated decrease in renal function after using the ACE inhibitors and ARB, but it is neither a sensitive nor specific finding. Aggressive statin use, optimal glycemic regulation, and therapy for smoking abstinence are of vital significance. Other modalities used are renal artery revascularization, Percutaneous transluminal renal angioplasty, Renal artery stenting, brachytherapy and cutting balloon atherotomy, and surgery in complicated and nonresponding cases. Although morbidity and mortality are higher associated with surgery as compared to stenting.

Treatment

Medical Therapy

Patients with Renal artery stenosis require the widespread use of intensive medical therapy. The drugs responsible for the management of renal artery stenosis are ACE inhibitors or ARB's. These drugs inhibit the sympathetic and renin-angiotensin system resulting in controlling hypertension. In patients with bilateral renal artery stenosis, there is an associated decrease in the renal function after using the ACE inhibitors and ARB, but it is neither sensitive nor specific[1]. Aggressive statin use, optimal glycemic regulation, and therapy for smoking abstinence are of vital significance.

Aggressive use of statins, optimal glycemic control, and smoking cessation counseling is of paramount importance. The results of various medical regimens on the treatment of ARAS-related hypertension were not analyzed in a randomized clinical trial because such patients frequently have refractory hypertension and need multiple antihypertensive medicines. Medical therapy is preferred for revascularization in patients with ARAS and progressive renal disease (i.e. chronic renal dysfunction, proteinuria[>1 g/d]), diffuse intrarenal vascular disease, and renal atrophy[2].

Renal Artery Revascularization

It is less obvious and much more contentious whether patients with ARAS and hypertension would undergo surgical revascularization. According to studies patients with extreme ostial renal artery stenosis who have been successfully revascularized percutaneously do not necessarily have therapeutic benefits.

The ACC/AHA description of RAS is as follows:

(1) visually approximate stenosis of 50 percent to 70 percent diameter with a translational peak gradient of at least 20 mm Hg or a mean gradient of at least 10 mm Hg

(2) angiographic stenosis of at least 70 percent diameter

(3) greater than 70% stenosis according to the measurement by intravascular ultrasounds[3].

Present ACC/AHA recommendations do not, however, include these steps and prescribe revascularization of ARAS only when it is associated with certain medical conditions mentioned as follows:

1) Asymptomatic stenosis: Percutaneous revascularization can be considered for the treatment of:

  • An asymptomatic bilateral
  • The efficacy of percutaneous or asymptomatic unilateral hemodynamically significant ARAS in a viable kidney is not well known and clinically unrecognized (class 11b, LOE C)

2) Hypertension


3) Preservation of renal function


4) Effects of renal artery stenosis on Congestive heart failure and unstable angina: Percutaneous revascularization is considered in patients with


Percutaneous Transluminal Renal Angioplasty

Renal Artery Stenting

Additional Interventional Procedures

Surgery

References


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  2. Bokhari SW, Faxon DP (2004). "Current advances in the diagnosis and treatment of renal artery stenosis". Rev Cardiovasc Med. 5 (4): 204–15. PMID 15580159.
  3. Olin JW (May 1994). "Role of duplex ultrasonography in screening for significant renal artery disease". Urol Clin North Am. 21 (2): 215–26. PMID 8178389.
  4. van Jaarsveld BC, Krijnen P, Pieterman H, Derkx FH, Deinum J, Postma CT, Dees A, Woittiez AJ, Bartelink AK, Man in 't Veld AJ, Schalekamp MA (April 2000). "The effect of balloon angioplasty on hypertension in atherosclerotic renal-artery stenosis. Dutch Renal Artery Stenosis Intervention Cooperative Study Group". N Engl J Med. 342 (14): 1007–14. doi:10.1056/NEJM200004063421403. PMID 10749962.
  5. Dorros G, Jaff M, Mathiak L, Dorros II, Lowe A, Murphy K, He T (August 1998). "Four-year follow-up of Palmaz-Schatz stent revascularization as treatment for atherosclerotic renal artery stenosis". Circulation. 98 (7): 642–7. doi:10.1161/01.cir.98.7.642. PMID 9715856.
  6. Blum U, Krumme B, Flügel P, Gabelmann A, Lehnert T, Buitrago-Tellez C, Schollmeyer P, Langer M (February 1997). "Treatment of ostial renal-artery stenoses with vascular endoprostheses after unsuccessful balloon angioplasty". N Engl J Med. 336 (7): 459–65. doi:10.1056/NEJM199702133360702. PMID 9017938.
  7. Leertouwer TC, Gussenhoven EJ, Bosch JL, van Jaarsveld BC, van Dijk LC, Deinum J, Man In 't Veld AJ (July 2000). "Stent placement for renal arterial stenosis: where do we stand? A meta-analysis". Radiology. 216 (1): 78–85. doi:10.1148/radiology.216.1.r00jl0778. PMID 10887230.
  8. 8.0 8.1 Wheatley K, Ives N, Gray R, Kalra PA, Moss JG, Baigent C, Carr S, Chalmers N, Eadington D, Hamilton G, Lipkin G, Nicholson A, Scoble J (November 2009). "Revascularization versus medical therapy for renal-artery stenosis". N Engl J Med. 361 (20): 1953–62. doi:10.1056/NEJMoa0905368. PMID 19907042.
  9. Cooper CJ, Murphy TP, Matsumoto A, Steffes M, Cohen DJ, Jaff M, Kuntz R, Jamerson K, Reid D, Rosenfield K, Rundback J, D'Agostino R, Henrich W, Dworkin L (July 2006). "Stent revascularization for the prevention of cardiovascular and renal events among patients with renal artery stenosis and systolic hypertension: rationale and design of the CORAL trial". Am Heart J. 152 (1): 59–66. doi:10.1016/j.ahj.2005.09.011. PMID 16824832.
  10. Jahraus CD, Meigooni AS (April 2004). "Vascular brachytherapy: a new approach to renal artery in-stent restenosis". J Invasive Cardiol. 16 (4): 224–7, quiz (page following). PMID 15152154.
  11. Otah KE, Alhaddad IA (October 2004). "Intravascular ultrasound-guided cutting [[balloon angioplasty]] for [[renal artery]] [[stent]] [[restenosis]]". Clin Cardiol. 27 (10): 581–3. doi:10.1002/clc.4960271012. PMC 6654343 Check |pmc= value (help). PMID 15553312. URL–wikilink conflict (help)
  12. Granillo GA, van Dijk LC, McFadden EP, Serruys PW (January 2005). "Percutaneous radial intervention for complex bilateral renal artery stenosis using paclitaxel eluting stents". Catheter Cardiovasc Interv. 64 (1): 23–7. doi:10.1002/ccd.20240. PMID 15619320.
  13. White CW, Wright CB, Doty DB, Hiratza LF, Eastham CL, Harrison DG, Marcus ML (March 1984). "Does visual interpretation of the coronary arteriogram predict the physiologic importance of a coronary stenosis?". N Engl J Med. 310 (13): 819–24. doi:10.1056/NEJM198403293101304. PMID 6700670.