Renal artery stenosis resident survival guide: Difference between revisions

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==Definition==
==Overview==
This section provides a short and straight to the point definition of the disease or symptom in one sentence.
Renal artery stenosis is defined as a dimished diameter of the lumen of the renal artery.
Renal artery of >70% is considered hemodynamically significant.<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=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. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>


==Causes==
==Causes==
===Life Threatening Causes===
===Life Threatening Causes===
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
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.
* [[Life threatening cause 1]]
* [[Life threatening cause 2]]
* [[Life threatening cause 3]]


===Common Causes===
===Common Causes===
* [[Common cause 1]]
* [[Atherosclerosis]]
* [[Common cause 2]]
* [[Fibromuscular dysplasia]]
* [[Common cause 3]]
* [[Neurofibromatosis]]
* [[Common cause 4]]
* [[Vasculitis]]
* [[Common cause 5]]
* [[Congenital|Congenital bands]]
* [[Radiation]]
 
==Management==
===Diagnostic Approach===
Shown below is the diagnostic approach to RAS based on the 2013 AHA Guidelines Recommendations for Management of Patients with PAD.<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=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. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>


==Clinical Clues to the Diagnosis of RAS==
{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | A01 | | | A01= '''Determine if one or more of the above is present'''}}
{{familytree | | | | | A01 | |A01='''Determine if one or more of the following is present:''' <br> <div style="float: left; text-align: left; height: 17em; width: 37em; padding:1em;"> Onset of hypertension before the age of 30 years <br> ❑ Onset of severe hypertension after the age of 55<br> Accelerated, resistant, or [[malignant hypertension]]<br> Development of new [[azotemia]] or worsening renal function after administration of an [[ACE inhibitor]] or [[ARB]] agent<br> Unexplained [[atrophic kidney]] or size discrepancy between kidneys >1.5 cm<br> Sudden, unexplained pulmonary edema<br> Unexplained renal dysfunction, including individuals starting renal replacement therapy<br>Multi-vessel [[CAD]]<br> Unexplained [[CHF]]<br> Refractory [[angina]] </div>}}
{{familytree | | | | | | |!| | | | | | | | }}
{{familytree | | | | | |!| | | | | | | | | | | | }}
{{familytree | | | | | | A02 | | A02= <table class="wikitable">
{{familytree | | | | | B01 | | | | | | | B01=<div style="float: left; text-align: left; height: 2em; width: 37em; padding:1em;">❑ Proceed with non-invasive imaging <ref name="pmid21719621‎">{{cite journal| author=Lao D, Parasher PS, Cho KC, Yeghiazarians Y| title=Atherosclerotic renal artery stenosis--diagnosis and treatment. | journal=Mayo Clin Proc | year= 2011 | volume= 86 | issue= 7 | pages= 649-57 | pmid=21719621‎ | doi=10.4065/mcp.2011.0181 | pmc=PMC3127560 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21719621  }} </ref><br> </div>}}
<tr class="v-firstrow"><th>Scenario</th><th>Level of evidence</th></tr>
{{familytree | | | | | |!| | | | | | | | | | | }}
<tr><td>'''1.'''Onset of hypertension before the age of 30 years or severe hypertension after the age of 55</td><td>Class I; LOE B</td></tr>
{{familytree | | | | | C01 | | | | | | | | | | | C01=<div style="float: left; text-align: left; height: 1em; width: 37em; padding:1em;">'''Is the patient allergic to contrast?'''</div>}}
<tr><td>'''2.''' Accelerated, resistant, or malignant hypertension</td><td>Class I; LOE C</td></tr>
{{familytree | | |,|-|-|^|-|-|.| | | | | | | | | | }}
<tr><td>'''3.''' Development of new azotemia or worsening renal function after administration of an ACE inhibitor or ARB agent</td><td>Class I; LOE B</td></tr>
{{familytree | | C02 | | | | C03 | | | | | | | | | C02= '''Yes'''| C03= '''No'''}}
<tr><td>'''4.''' Unexplained atrophic kidney or size discrepancy between kidneys of greater than 1.5 cm</td><td>Class I; LOE B</td></tr>
{{familytree | | |!| | | | | |!| | | | | | | | | | }}
<tr><td>'''5.''' Sudden, unexplained pulmonary edema</td><td>Class I; LOE B</td></tr>
{{familytree | | |!| | | | | D01 | | | | | | | D01= <div style="float: left; text-align: left; height: 12em; width: 20em; padding:1em;">'''Does the patient has any of the following?'''<br> ❑ Implanted devices:<br> - [[Pacemaker]]s<br> - [[Defibrillator]]s<br> - [[Cochlear implants]]<br> - Spinal cord stimulators <br> ❑ [[Claustrophobia]] </div>}}
<tr><td>'''6.''' Unexplained renal dysfunction, including individuals starting renal replacement therapy</td><td>Class IIa; LOE B</td></tr>
{{familytree | | |!| | | |,|-|^|-|.| | | | | | | |}}
<tr><td>'''7.''' Multi-vessel coronary artery disease</td><td>Class IIb; LOE B</td></tr>
{{familytree | | |!| | | D03 | | D04 | | | | | | | D03= '''No'''| D04= '''Yes'''}}
<tr><td>'''8.''' Unexplained congestive heart failure</td><td>Class IIb; LOE C</td></tr>
{{familytree | | |!| | | |!| | | |!| | | | | | | |}}
<tr><td>'''9.''' Refractory angina</td><td>Class IIb; LOE C</td></tr>
{{familytree | | E01 | | E02 | | E03 | | | | | | | | | E01=❑ Proceed with [[US]]| E02= ❑ Proceed with [[MRA]] | E03= ❑ Proceed with [[CT]]}}
</table>}}
{{familytree | | |`|-|-|-|+|-|-|-|'| | | | | | |}}
{{familytree | | | | | | |!| | | | | | | | | | }}
{{familytree | | | | |,|-|^|-|.| | | | | | | | |}}
{{familytree | | | | | | A01 | | | A01= ❑'''If one or more of the above are present, proceed to further diagnostic testing'''}}
{{familytree | | | | F01 | | F02 | | | | | | F01= '''Inconclusive noninvasive test but with high clinical index of suspicion:''' <br>❑ Perform [[angiography|catheter angiography]] | F02= '''Confirmed RAS:''' <br> ❑ Proceed to treatment}}
{{familytree | | | | | | |!| | | | | | | | | | }}
{{familytree | | | |,|-|-|^|-|-|.| | }}
 
{{familytree | | | B01 | | | | B02 | B01=<div style="height: 1em; width: 25em; padding:1em;">'''Noninvasive Imaging'''
</div>| B02= <div style="height: 1em; width: 25em; padding:1em;">'''Invasive Imaging'''
</div>}}
 
{{familytree | | | |!| | | | | |!| | }}
 
{{familytree | | | C01 | | | | C02 | C01= <div style="float: left; text-align: left; height: 5em; width: 25em; padding:1em;">❑ Duplex ultrasound
❑ Gadolinium enhanced MRA
❑ CT angiography </div>| C02= <div style="height: 3em; width: 25em;">❑ Abdominal aortography to assess the renal arteries during coronary and peripheral angiography</div>}}
{{familytree | | | |!| | | | | |!| | | | | }}
{{familytree | |,|-|^|-|.| | | |!||}}
{{familytree | |!| | | |!| | | |!| | | | | }}
{{familytree | C01 | | C02 | | C03 | C01= <div style="height: 5em; width: 10em;">Negative noninvasive test but with high clinical suspicion </div>| C02= <div style="height: 3em; width: 10em;">Evidence of RAS </div>| C03= <div style="height: 3em; width: 10em;">Evidence of RAS </div>}}
{{familytree | |!| | | |!| | | |!| | | | | }}
{{familytree | C01 | | |!| | | |!| C01= <div style="height: 2em; width: 10em; padding:1em;">Renal angiography</div>}}
{{familytree | |!| | | |!| | | |!| | | | | }}
{{familytree | C01 | | |!| | | |!| C01= <div style="height: 2em; width: 10em; padding:1em;">Evidence of RAS</div>}}
{{familytree | |!| | | |!| | | |!| | | | | }}
{{familytree | C01 |-|-|^|-|-|-|'| C01= <div style="height: 4em; width: 10em; padding:1em;">'''Confirmed RAS, proceed to treatment'''</div>}}
{{familytree/end}}
{{familytree/end}}


Algorithm based on the 2013 AHA Guidelines Recommendations for Management of Patients with PAD.<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=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. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>
<br>


==Indications for Renal Revascularization==
=== Therapeutic Approach===
<table class="wikitable">
Shown below is the diagnostic approach to RAS based on the 2013 AHA Guidelines Recommendations for Management of Patients with PAD.<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=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. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>
<tr class="v-firstrow"><th>Indication</th><th>Level of evidence</th></tr>
<tr><td>'''1.'''Hemodynamically significant RAS with recurrent, unexplained CHF or sudden, unexplained pulmonary edema</td><td>Class I; LOE B</td></tr>
<tr><td>'''2.''' RAS with:
*Accelerated, resistant, or malignant hyper tension
*Hypertension with unilateral small kidney
*Hypertension with medication intolerance</td><td>Class IIa; LOE B</td></tr>
<tr><td>'''3.'''RAS and [[CRI]] with bilateral RAS or RAS to solitary functioning kidney</td><td>Class IIa; LOE B</td></tr>
<tr><td>'''4.''' RAS and unstable angina</td><td>Class IIa; LOE B</td></tr>
<tr><td>'''5.''' Asymptomatic bilateral or solitary viableʰ kidney with a hemodynamically significant RAS</td><td>Class IIb; LOE C</td></tr>
<tr><td>'''6.''' Asymptomatic unilateral hemodynamically significant RAS in a viable* kidney</td><td>Class IIb; LOE C</td></tr>
<tr><td>'''7.''' RAS and [[CRI]] with unilateral RAS (2 kidneys present)</td><td>Class IIb; LOE C</td></tr>
</table>
 
ʰViable means kidney linear length greater than 7 cm   


{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | | | A01 | | | A01= '''When any of the indications are met:'''}}
{{familytree | | | A01 | |A01='''Initiate a regimen that combines:'''<ref name="pmid22279335">{{cite journal| author=Annigeri RA| title=Medical therapy is best for atherosclerotic renal artery stenosis: Arguments for. | journal=Indian J Nephrol | year= 2012 | volume= 22 | issue= 1 | pages= 1-4 | pmid=22279335 | doi=10.4103/0971-4065.91177 | pmc=PMC3263056 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22279335  }} </ref> <br> <div style="float: left; text-align: left; height: 21em; width: 30em; padding:1em;"> ❑ Tight blood pressure control to <130/80 mmHg (120/75 mmHg if proteinuria is present) with:
{{familytree | | | | | | | | | |!| | | | | }}
♦ [[ACEI]], or<br>
{{familytree | | | | | | |,|-|-|^|-|-|.| | }}
♦ [[ARB]], or<br>
{{familytree | | | | | | A01 | | | | A02 | | A01= '''Renal Angioplasty/Stent'''| A02= ❑ Renal artery surgery}}
♦ [[CCB]], or<br>
{{familytree | | | | | | |!| | | | | | | | | | }}
♦ [[Beta blockers]] <br> ❑ Control of hyperlipidemia (LDL cholesterol <70 mg/dl) with [[statins]] <br> ❑ Glycemic control (hemoglobin A1c <7%) <br>  ❑ [[Antiplatelet]] agents <br> ❑ Life style modifications:<br>
{{familytree | | | |,|-|-|^|-|-|.| | }}
♦ Smoking cessation counseling
{{familytree | | | B01 | | | | B02 | B01=<div style="height: 1em; width: 25em; padding:1em;">'''Noninvasive Imaging'''  
♦ Normalization of body weight </div>}}
</div>| B02= <div style="height: 1em; width: 25em; padding:1em;">'''Invasive Imaging'''
{{familytree | | | |!| | | | | | }}
</div>}}
{{familytree | | | B01 | | | | | | | B01= '''Proceed to evaluate clinical indications for revascularization'''}}
 
{{familytree | | | |!| | | | | | | | }}
{{familytree | | | |!| | | | | |!| | }}
{{familytree | | | C01 | | | | | C01= '''Does the patient has any of the following?'''<br> <div style="float: left; text-align: left; height: 19em; width: 30em; padding:1em;"> ❑ RAS with: <br>
 
- Accelerated, resistant, or [[malignant hypertension]] <br>
{{familytree | | | C01 | | | | C02 | C01= <div style="float: left; text-align: left; height: 5em; width: 25em; padding:1em;">❑ Duplex ultrasound
- [[Hypertension]] with an unexplained unilateral small kidney <br>
Gadolinium enhanced MRA
- [[Hypertension]] with medication intolerance <br> ❑ Progressive [[CKD]] with bilateral RAS or RAS to a solitary functioning kidney <br> ❑ Hemodynamically significant RAS  with recurrent, unexplained[[CHF]] or sudden, unexplained [[pulmonary edema]] <br> ❑ [[Unstable angina]] <br> ❑ Asymptomatic bilateral or solitary viable kidney <br> ❑ [[Chronic renal failure]] with unilateral RAS </div>}}
❑ CT angiography </div>| C02= <div style="height: 3em; width: 25em;">❑ Abdominal aortography to assess the renal arteries during coronary and peripheral angiography</div>}}
{{familytree | | | |!| | | | | | }}
{{familytree | |,|-|^|-|.| | | | }}
{{familytree | D01 | | D02 | | D01='''If any of the above AND:'''<br><div style="float: left; text-align: left; height: 8em; width: 20em; padding:1em;"> ❑ [[Atherosclerosis|Ostial atherosclerotic RAS]], '''OR'''<br>  [[Fibromuscular dysplasia]] </div> | D02= '''If any of the above AND:''' <br><div style="float: left; text-align: left; height: 8em; width: 20em; padding:1em;"> ❑ Complex [[fibromuscular dysplasia]] disease that extends into segmental arteries, '''OR''' <br> ❑ [[Aneurysm|Macroaneurysms]], '''OR''' <br> ❑ [[Atherosclerosis|Atherosclerotic]] RAS with multiple small renal arteries or early primary branching of the main [[renal artery]]</div> }}
{{familytree | |!| | | |!| | | | | }}
{{familytree | E01 | | E02 | E01=Endovascular treatment | E02=Renal artery surgery }}  
{{familytree/end}}
{{familytree/end}}



Latest revision as of 00:25, 13 March 2014

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. doi:10.1161/CIR.0b013e31828b82aa. PMID 23457117.
  2. Lao D, Parasher PS, Cho KC, Yeghiazarians Y (2011). "Atherosclerotic renal artery stenosis--diagnosis and treatment". Mayo Clin Proc. 86 (7): 649–57. doi:10.4065/mcp.2011.0181. PMC 3127560. PMID 21719621‎ Check |pmid= value (help).
  3. Annigeri RA (2012). "Medical therapy is best for atherosclerotic renal artery stenosis: Arguments for". Indian J Nephrol. 22 (1): 1–4. doi:10.4103/0971-4065.91177. PMC 3263056. PMID 22279335.


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