Renal artery stenosis medical therapy
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yazan Daaboul, Serge Korjian, Vishnu Vardhan Serla M.B.B.S. [2]
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Overview
Angiotensin Converting Enzyme (ACE) inhibitors or a calcium channel blocker (CCB) are first line therapy in both unilateral and bilateral renal artery stenosis.
Medical Therapy
The following are the list of medications indicated for patients with unilateral renal artery stenosis (RAS) with their corresponding level of evidence, based on 2013 ACC/AHA Guidelines for the Management of PAD[1]
| Medication Class | Level of Evidence |
| ACE-Inhibitors | A |
| Calcium Channel Blockers | A |
| Beta-Blockers | A |
| ARB | B |
- The recommended initial pharmacologic therapy in patients with RAS is either an Angiotensin converting enzyme inhibitor (ACE-I) or a calcium channel blocker (CCB), both of which have been proven effective not only for lowering blood pressure values, but also for delaying the progression of renal disease.[2][3][4][5][6] Other well-established therapies for lowering blood pressures in patients with RAS include beta-blockers,chlorothiazides, and hydrazine.[6] ARBs can also be used to treat hypertension associated with unilateral RAS.[1] These recommendations for management of hypertension are based upon guidelines from the JNC in 2004[7] and/or ESH/ESC guidelines in 2013[8].
- Diuretics can also be administered to treat the hypertension associated with renal artery stenosis.
- Co-morbidities like diabetes, heart disease, or hardening of the arteries should be treated as well.
- Lifestyle changes are important and they include:
- Healthy diet
- Regular exercise
- Smoking cessation
- Limiting alcohol intake: 1 drink a day for women, 2 a day for men
- Limited sodium (salt) intake less than 1,500 mg per day. Check with your doctor about how much potassium you should be eating.
- Stress reduction
- Maintain a healthy body weight
Complications of ACE and ARB therapy
There is ongoing debate as to whether ACE inhibitors and ARBs offer a net benefit when hypertensive control and renal perfusion are both considered. Careful monitoring of the creatinine in these patients is critical to assure that the patient does not reach a tipping point where renal perfusion is so reduced that they develop ischemic atrophy.
Unilateral or bilateral renal artery stenosis reduce renal perfusion which in turn activates the renin-angiotensin-aldosterone system (RAAS). Activation of the RAAS system in turn reduces Na excretion and expands intravascular volume. ACE inhibition and diuretics are therefore well suited to blocking this pathophysiologic response to a stenosis.
As the blood pressure is lowered with antihypertensive treatment, this may further reduce renal perfusion, and at a certain point may further lower the glomerular filtration rate (GFR) causing the creatinine to go up. Both ACE inhibitors and ARB block the usual autoregulatory response to compensate for reduced renal perfusion which would be to increase the postcapillary resistance. There is concern that sustained reductions in renal perfusion may lead to ischemic atrophy of the kidney.
The rise in creatinine (Cr) with the use of ACE inhibtors and ARBS is not a contraindication to their use since the decline in glomerular filtration rate with their use is generally small with only 5-10% of patients having a 30% or greater rise in creatinine. Nonetheless, the creatinine should be carefully monitored. If the creatinine does rise to near 30%, then either the diuretic or the ACE inhibitor or the ARB can be discontinued.
In those patients who develop a significant rise in Cr after ACE inhibition, the reduction in blood pressure may not allow maintenance of renal perfusion, and these patients should be considered candidates for percuatenous or surgical revascularization.
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[9]
| Class I |
| "1. Angiotensin-converting enzyme inhibitors are effective medications for treatment of hypertension associated with unilateral RAS. (Level of Evidence: A)" |
| "2. Angiotensin receptor blockers are effective medications for treatment of hypertension associated with unilateral RAS. (Level of Evidence: B)" |
| "3. Calcium-channel blockers are effective medications for treatment of hypertension associated with unilateral RAS. (Level of Evidence: A)" |
| "4. Beta-blockers are effective medications for treatment of hypertension associated with RAS. (Level of Evidence: A)" |
References
- ↑ 1.0 1.1 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. doi:10.1161/CIR.0b013e31828b82aa. PMID 23457117.
- ↑ Plouin PF (2003). "Stable patients with atherosclerotic renal artery stenosis should be treated first with medical management". Am J Kidney Dis. 42 (5): 851–7. PMID 14582030.
- ↑ Nordmann AJ, Woo K, Parkes R, Logan AG (2003). "Balloon angioplasty or medical therapy for hypertensive patients with atherosclerotic renal artery stenosis? A meta-analysis of randomized controlled trials". Am J Med. 114 (1): 44–50. PMID 12557864.
- ↑ Webster J, Marshall F, Abdalla M, Dominiczak A, Edwards R, Isles CG; et al. (1998). "Randomised comparison of percutaneous angioplasty vs continued medical therapy for hypertensive patients with atheromatous renal artery stenosis. Scottish and Newcastle Renal Artery Stenosis Collaborative Group". J Hum Hypertens. 12 (5): 329–35. PMID 9655655.
- ↑ Plouin PF, Chatellier G, Darné B, Raynaud A (1998). "Blood pressure outcome of angioplasty in atherosclerotic renal artery stenosis: a randomized trial. Essai Multicentrique Medicaments vs Angioplastie (EMMA) Study Group". Hypertension. 31 (3): 823–9. PMID 9495267.
- ↑ 6.0 6.1 Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B (2006). "ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation". Circulation. 113 (11): e463–654. doi:10.1161/CIRCULATIONAHA.106.174526. PMID 16549646. Retrieved 2012-10-09. Unknown parameter
|month=ignored (help) - ↑ Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL; et al. (2003). "The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report". JAMA. 289 (19): 2560–72. doi:10.1001/jama.289.19.2560. PMID 12748199.
- ↑ Mancia G, Fagard R, Narkiewicz K, Redán J, Zanchetti A, Böhm M; et al. (2013). "2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension". J Hypertens. 31 (10): 1925–38. doi:10.1097/HJH.0b013e328364ca4c. PMID 24107724.
- ↑ Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss L; 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". J Am Coll Cardiol. 61 (14): 1555–70. doi:10.1016/j.jacc.2013.01.004. PMC 4492473. PMID 23473760.