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| {{Infobox_Disease |
| | __NOTOC__ |
| Name = {{PAGENAME}} |
| | {{Renal artery stenosis}} |
| Image = Kidney PioM.png |
| | {| class="infobox" style="float:right;" |
| Caption = [[Renal artery]] is #3 |
| | |} |
| DiseasesDB = 11255 |
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| ICD10 = |
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| ICD9 = {{ICD9|440.1}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = 001273 |
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| eMedicineSubj = med |
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| eMedicineTopic = 2001 |
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| }}
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| [[Image:Renal artery stenosis diagram 001.gif|thumb|200px|Illustration of renal artery stenosis]]
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| {{SI}}
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| {{CMG}} | | {{CMG}}; '''Associate Editor-In-Chief:''' {{Shivam Singla}} |
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| '''Associate Editor-In-Chief:''' {{CZ}}
| | {{SK}} RAS; renovascular hypertension; atherosclerotic renal artery stenosis; ARAS |
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| {{Editor Join}}
| | ==[[Renal artery stenosis overview|Overview]]== |
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| ==Overview== | | ==[[Renal artery stenosis pathophysiology|Pathophysiology]]== |
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| '''Renal artery stenosis''' is the narrowing of the [[renal artery]], most often caused by [[atherosclerosis]] or [[fibromuscular dysplasia]]. This narrowing of the renal artery can impede blood flow to the target kidney. Hypertension and atrophy of the affected [[kidney]] may result from renal artery stenosis, ultimately leading to [[renal failure]] if not treated.
| | ==[[Renal artery stenosis causes|Causes]]== |
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| ==Etiology== | | ==[[Renal artery stenosis classification|Classification]]== |
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| Atherosclerosis is the predominant cause of renal artery stenosis in the majority of patients, usually those with a sudden onset of hypertension at age 50 or older. Fibromuscular dysplasia is the predominant cause in young patients, usually females under 40 years of age. A variety of other causes exist. These include [[arteritis]], [[aneurysm|renal artery aneurysm]], extrinsic compression (eg. [[neoplasm]]s), neurofibromatosis, and fibrous bands.
| | ==[[Renal artery stenosis epidemiology and demographics|Epidemiology and Demographics]]== |
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| ==Pathophysiology== | | ==[[Renal artery stenosis risk factors|Risk Factors]]== |
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| The [[macula densa]] of the kidney senses a decreased systemic blood pressure due to the pressure drop over the stenosis. The response of the kidney to this decreased blood pressure is activation of the [[renin-angiotension aldosterone system]], which normally counteracts low blood pressure, but in this case lead to hypertension (high blood pressure). The decreased perfusion pressure (caused by the stenosis) leads to decreased blood flow ([[hypoperfusion]]) to the kidney and a decrease in the [[Glomerular filtration rate|GFR]]. If the stenosis is long standing and severe the GFR in the affected kidneys never increases again and (pre-renal) [[renal failure]] is the result.
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| ==Signs and symptoms==
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| Most cases of renal artery stenosis are asymptomatic, and the main problem is [[high blood pressure]] that cannot be controlled with medication. Deterioration in [[renal function]] may develop if both kidneys are poorly supplied, or when treatment with an [[ACE inhibitor]] is initiated. Some patients present with episodes of [[flash pulmonary edema]] (sudden left ventricular heart failure).<ref>{{cite journal |author=Pickering TG, Herman L, Devereux RB, ''et al'' |title=Recurrent pulmonary oedema in hypertension due to bilateral renal artery stenosis: treatment by angioplasty or surgical revascularisation |journal=Lancet |volume=2 |issue=8610 |pages=551-2 |year=1988 |pmid=2900930 |doi=}}</ref>
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| ==Differential Diagnosis==
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| * [[Acute renal failure]]
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| * [[Atherosclerosis]]
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| * [[Chronic glomerulonephritis]]
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| * [[Hypersensitivity nephropathy]]
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| * [[Hypertension]]
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| * [[Malignant hypertension]]
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| * [[Nephrosclerosis]]
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| * [[Renovascular hypertension]]
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| * [[Uremia]]
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| ==Diagnosis== | | ==Diagnosis== |
| | | [[Renal artery stenosis diagnostic criteria|Diagnostic Criteria]] | [[Renal artery stenosis history and symptoms|History and Symptoms]] | [[Renal artery stenosis physical examination|Physical Examination]] | [[Renal artery stenosis x ray|X Ray]] | [[Renal artery stenosis CT|CT]] | [[Renal artery stenosis MRI|MRI]] | [[Renal artery stenosis ultrasound|Echocardiography or Ultrasound]] |
| A [[clinical prediction rule]] is available to guide diagnosis.<ref name="pmid9841602">{{cite journal|author=Krijnen P, van Jaarsveld BC, Steyerberg EW, Man in 't Veld AJ, Schalekamp MA, Habbema JD|title=A clinical prediction rule for renal artery stenosis|journal=Ann. Intern. Med.|volume=129|issue=9|pages=705–11|year=1998|pmid=9841602}}</ref>
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| * refractory [[hypertension]] - high blood pressure that can not be controlled adequately with [[antihypertensives]]
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| * [[auscultation]] (with [[stethoscope]]) - [[bruit]] ("rushing" sound) on affected side, inferior of the [[costal margin]]
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| * [[captopril challenge test]]
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| * captopril test dose effect on the differential renal function as measured by [[MAG3 scan]].<ref name="pmid9351069">{{cite journal|author=Roccatello D, Picciotto G|title=Captopril-enhanced scintigraphy using the method of the expected renogram: improved detection of patients with renin-dependent hypertension due to functionally significant renal artery stenosis|journal=Nephrol. Dial. Transplant.|volume=12|issue=10|pages=2081–6|year=1997|pmid=9351069|doi= 10.1093/ndt/12.10.2081|url=http://ndt.oxfordjournals.org/cgi/reprint/12/10/2081.pdf|format=PDF}}</ref>
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| * renal artery [[angiogram|arteriogram]]
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| ==Diagnostic Findings==
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| [http://www.peir.net Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology] | |
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| <gallery perRow="3">
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| Image:Renal artery stenosis 001.jpg|Renal artery stenosis. The patient is a 75 year old white female with a history of hypertension. she is s/p left nephrectomy approximately 10 years ago for renal cell carcinoma. 1. Definite renal artery stenosis involving the origin of the right renal artery. 2. Focal dilatation of the distal abdominal aorta, but no frank aneurysm.
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| Image:Renal artery stenosis 002.jpg|Renal artery stenosis. The patient is a 75 year old white female with a history of hypertension. she is s/p left nephrectomy approximately 10 years ago for renal cell carcinoma. 1. Definite renal artery stenosis involving the origin of the right renal artery. 2. Focal dilatation of the distal abdominal aorta, but no frank aneurysm.
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| Image:Renal artery stenosis 003.jpg|
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| Image:Renal artery stenosis 004.jpg|
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| Image:Renal artery stenosis 005.jpg|
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| Image:Renal artery stenosis 006.jpg|
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| Image:Renal artery stenosis 007.jpg|
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| Image:Renal artery stenosis 008.jpg|
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| Image:Renal artery stenosis 009.jpg|
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| Image:Renal artery stenosis 010.jpg|
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| Image:Renal artery stenosis 011.jpg|
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| Image:Renal artery stenosis 012.jpg|
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| Image:Renal artery stenosis 013.jpg|
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| Image:Renal artery stenosis 014.jpg|
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| Image:Renal artery stenosis 015.jpg|
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| Image:Renal artery stenosis 016.jpg|
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| Image:Renal artery stenosis 017.jpg|
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| Image:Renal artery stenosis 018.jpg|
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| Image:Renal artery stenosis 019.jpg|
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| Image:Renal artery stenosis 020.jpg|
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| Image:Renal artery stenosis 021.jpg|
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| Image:Renal artery stenosis 022.jpg|
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| Image:Renal artery stenosis 023.jpg|
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| Image:Renal artery stenosis 024.jpg|
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| Image:Renal artery stenosis 025.jpg|
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| Image:Renal artery stenosis 026.jpg|
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| Image:Renal artery stenosis 027.jpg|
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| Image:Renal artery stenosis 028.jpg|
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| Image:Renal artery stenosis 029.jpg|
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| Image:Renal artery stenosis 030.jpg|
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| Image:Renal artery stenosis 031.jpg|
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| Image:Renal artery stenosis 032.jpg|
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| Image:Renal artery stenosis 033.jpg|
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| Image:Renal artery stenosis 034.jpg|
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| Image:Renal artery stenosis 035.jpg|
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| Image:Renal artery stenosis 036.jpg|
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| Image:Renal artery stenosis 037.jpg|
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| Image:Renal artery stenosis 038.jpg|
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| Image:Renal artery stenosis 039.jpg|
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| Image:Renal artery stenosis 040.jpg|
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| Image:Renal artery stenosis 041.jpg|
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| Image:Renal artery stenosis 042.jpg|
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| Image:Renal artery stenosis 043.jpg|
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| Image:Renal artery stenosis 044.jpg|
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| Image:Renal artery stenosis 045.jpg|
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| Image:Renal artery stenosis 046.jpg|
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| Image:Renal artery stenosis 047.jpg|
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| </gallery>
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| ==Treatment== | | ==Treatment== |
| | [[Renal artery stenosis medical therapy|Medical Therapy]] | [[Renal artery stenosis angioplasty and stenting|Angioplasty and Stenting]] | [[Renal artery stenosis surgery|Surgery]] |
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| When high-grade renal artery stenosis is documented and blood pressure cannot be controlled with medication, or if renal function deteriorates, renal artery stenosis is often treated invasively. Renal artery stenosis is most commonly treated by endovascular techniques (i.e. [[angioplasty]] with or without [[stent]]ing). A 2003 [[meta-analysis]] found that angioplasty was safe and effective in this context.<ref>{{cite journal |author=Nordmann AJ, Woo K, Parkes R, Logan AG |title=Balloon angioplasty or medical therapy for hypertensive patients with atherosclerotic renal artery stenosis? A meta-analysis of randomized controlled trials |journal=Am. J. Med. |volume=114 |issue=1 |pages=44-50 |year=2003 |pmid=12557864 |doi=}}</ref> There are ongoing clinical trials to compare medical management and angioplasty with stenting to medical management alone. These include CORAL and ASTRAL, both scheduled to report results in 2010. In addition to endovascular treatment, surgical resection and anastomosis is a rarely-used option.
| | ==Case Studies== |
| | | [[Renal artery stenosis case study one|Case #1]] |
| ===Life Style Modification===
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| The first step in treating RAS is making lifestyle changes that promote healthy blood vessels in general. Exercising, controlling weight, and choosing healthy foods may help to keep arteries disease free and flexible. Smoking cessation is one of the best things to save kidneys and other organs.
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| ===Blood Pressure Control===
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| RAS causes high blood pressure, which can damage the kidneys. Damaged kidneys, in turn, can make your blood pressure even higher. If left uncontrolled, this vicious cycle can lead to kidney failure and damage the heart and blood vessels throughout the body.
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| Controlling renovascular hypertension is often difficult but usually achievable. It may require two or more different kinds of blood pressure medicine. Blood pressure medicines work in different ways.
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| Sometimes, by combining two or more blood pressure medicines that work in different ways, you may be able to control your blood pressure and stop the progression of kidney failure. Each type of blood pressure medicine has its own potential side effects; therefore, the choice of medicine is best determined by you and your doctor.
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| In addition to antihypertensives, prescription of a cholesterol lowering drug to prevent the plaques from forming in the arteries, and a blood-thinner, such as aspirin, to help the blood flow more easily through the arteries.
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| ===Angioplasty and stenting===
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| Angioplasty is a procedure in which a catheter is put into the renal artery, usually through the groin, just as in a conventional angiogram. In addition, for angioplasty, a tiny balloon at the end of the catheter can be inflated to flatten the plaque against the wall of the artery. Then your doctor may position a small mesh tube, called a stent, to keep plaque flattened and the artery open.
| | ==References== |
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| ===Surgery=== | |
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| If RAS advances until the artery is nearly or completely blocked, the patient may need surgery to open up the flow of blood to the kidney. Different types of surgery for RAS include the following:
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| ====Endarterectomy====
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| In an endarterectomy, a vascular surgeon removes the plaque
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| ====Bypass surgery====
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| To create a bypass, a vascular surgeon uses a vein or synthetic tube to connect the kidney to the aorta. This new path serves as an alternate route for blood to flow around the blocked artery into the kidney.
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| ==See also==
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| * [[Renovascular hypertension]]
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| ==Examples of Renal Artery Stenosis==
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| <youtube v=xeV3lmYi1Hk/>
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| * Right Renal Artery Stenosis
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| <youtube v=4UzLFatOg1Q/>
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| * Aortogram of Bilateral Renal Artery Stenosis
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| <youtube v=cL1TQFUU2Iw/>
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| ==Reference==
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| {{Reflist|2}} | | {{Reflist|2}} |
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| {{Circulatory system pathology}}
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| {{Nephrology}}
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| {{SIB}}
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| [[Category:Kidney diseases]] | | [[Category:Kidney diseases]] |
| [[Category:Nephrology]] | | [[Category:Nephrology]] |
| [[Category:Cardiology]] | | [[Category:Cardiology]] |
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