Renal artery stenosis diagnostic criteria: Difference between revisions

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__NOTOC__
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{{Renal artery stenosis}}
{{Renal artery stenosis}}
{{CMG}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{Shivam Singla}}


==Overview==
==Overview==
There are numerous tests and procedures involved in the detection of [[renal artery stenosis]]. [[Renal artery stenosis]] is best diagnosed with [[MRA]](Magnetic resonance Imaging), [[Doppler ultrasound]], [[Computed tomography]], [[renal scintigraphy]], peripheral renin levels, and [[renal vein sampling]]. Though these all modalities are used for making the diagnosis but still [[renal vein sampling]], [[renal scintigraphy]] is not the first choice for making the diagnosis of [[renal artery stenosis]] because of their low [[sensitivity]] and [[specificity]] which is around 38-40.


==Diagnosis==
==Diagnosis==
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>


* refractory [[hypertension]] - high blood pressure that can not be controlled adequately with [[antihypertensives]]
There are numerous tests and procedures involved in the detection of [[renal artery stenosis]]. [[Renal artery stenosis]] is best diagnosed with [[MRA]](Magnetic resonance Imaging), [[Doppler ultrasound]], [[Computed tomography]], [[renal scintigraphy]], peripheral [[renin levels]], and [[renal vein]] sampling. Though these all modalities are used for making the diagnosis but still [[renal vein]] sampling, [[renal scintigraphy]] are not the first choice for making the diagnosis of [[renal artery stenosis]] because of their low [[sensitivity]] and [[specificity]]<ref name="pmid11960229">{{cite journal |vauthors=Napoli V, Pinto S, Bargellini I, Vignali C, Cioni R, Petruzzi P, Salvetti A, Bartolozzi C |title=Duplex ultrasonographic study of the renal arteries before and after renal artery stenting |journal=Eur Radiol |volume=12 |issue=4 |pages=796–803 |date=April 2002 |pmid=11960229 |doi=10.1007/s003300101121 |url=}}</ref><ref name="pmid8610560">{{cite journal |vauthors=Grenier N, Trillaud H, Combe C, Degrèze P, Jeandot R, Gosse P, Douws C, Palussière J |title=Diagnosis of renovascular hypertension: feasibility of captopril-sensitized dynamic MR imaging and comparison with captopril scintigraphy |journal=AJR Am J Roentgenol |volume=166 |issue=4 |pages=835–43 |date=April 1996 |pmid=8610560 |doi=10.2214/ajr.166.4.8610560 |url=}}</ref> which is around 38-40.
* [[auscultation]] (with [[stethoscope]]) - [[bruit]] ("rushing" sound) on affected side, inferior of the [[costal margin]]
* [[captopril challenge test]]
* 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>
* renal artery [[angiogram|arteriogram]]


==2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic) (DO NOT EDIT)<ref name="pmid16549646">{{cite journal |author=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 |title=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 |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>==
The imaging modalities may be considered diagnostic if the following objectives are met:
===Clinical Clues to the Diagnosis of RAS (DO NOT EDIT)<ref name="pmid16549646">{{cite journal |author=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 |title=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 |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>===


{|class="wikitable"
(1) [[Anatomic]] and or [[Hemodynamic]] abnormality
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class I]]


|-
(2) Anatomic consequences and complications associated with [[renal artery stenosis]] (Post stenotic dilatation of [[renal artery]] can be seen with the use of [[CTA]] and [[MRA]], shrinkage of [[renal parenchyma]], with [[kidneys]] being < 8 cm.
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' The performance of diagnostic studies to identify clinically significant RAS is indicated in patients with the onset of hypertension before the age of 30 years. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>


|-
(3) [[Functional]] and [[cellular]] consequences of [[renal artery stenosis]]  
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' The performance of diagnostic studies to identify clinically significant RAS is indicated in patients with the onset of severe hypertension [as defined in The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC-7 report (294)] after the age of 55 years. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>


|-
(4) [[Renal]] impairment criteria related to [[renovascular disease]] should be me<ref name="pmid16356793">{{cite journal |vauthors=Grenier N, Hauger O, Cimpean A, Pérot V |title=Update of renal imaging |journal=Semin Nucl Med |volume=36 |issue=1 |pages=3–15 |date=January 2006 |pmid=16356793 |doi=10.1053/j.semnuclmed.2005.08.001 |url=}}</ref>.
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' The performance of diagnostic studies to identify clinically significant RAS is indicated in patients with the following characteristics: (a) accelerated hypertension (sudden and persistent worsening of previously controlled hypertension); (b) resistant hypertension (defined as the failure to achieve goal blood pressure in patients who are adhering to full doses of an appropriate 3-drug regimen that includes a diuretic); or (c) malignant hypertension (hypertension with coexistent evidence of acute end-organ damage, i.e., acute renal failure, acutely decompensated congestive heart failure, new visual or neurological disturbance, and/or advanced [grade III to IV] retinopathy). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>


|-
==='''<u>Ultrasonography</u>'''===
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' The performance of diagnostic studies to identify clinically significant RAS is indicated in patients with new azotemia or worsening renal function after the administration of an ACE inhibitor or an angiotensin receptor blocking agent (see text). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
[[Ultrasonography]] is readily available, secure, and inexpensive, and consequently is usually the first imaging study used to detect [[Renal artery stenosis]]. Usually, the results and accuracy are operator dependent and range in between 60-90%<ref name="pmid19917332">{{cite journal |vauthors=Zhang HL, Sos TA, Winchester PA, Gao J, Prince MR |title=Renal artery stenosis: imaging options, pitfalls, and concerns |journal=Prog Cardiovasc Dis |volume=52 |issue=3 |pages=209–19 |date=2009 |pmid=19917332 |doi=10.1016/j.pcad.2009.10.003 |url=}}</ref>.
This modality helps in the assessment of


|-
*[[Renal functional reserve]]
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' The performance of diagnostic studies to identify clinically significant RAS is indicated in patients with an unexplained atrophic kidney or a discrepancy in size between the 2 kidneys of greater than 1.5 cm. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
*[[Renal resistive index]]


|-
A [[renal artery]] EDV >90cm/s<ref name="pmid11172177">{{cite journal |vauthors=Radermacher J, Chavan A, Bleck J, Vitzthum A, Stoess B, Gebel MJ, Galanski M, Koch KM, Haller H |title=Use of Doppler ultrasonography to predict the outcome of therapy for renal-artery stenosis |journal=N Engl J Med |volume=344 |issue=6 |pages=410–7 |date=February 2001 |pmid=11172177 |doi=10.1056/NEJM200102083440603 |url=}}</ref> and RRI< 75-80<ref name="pmid11704015">{{cite journal |vauthors=Mukherjee D, Bhatt DL, Robbins M, Roffi M, Cho L, Reginelli J, Bajzer C, Navarro F, Yadav JS |title=Renal artery end-diastolic velocity and renal artery resistance index as predictors of outcome after renal stenting |journal=Am J Cardiol |volume=88 |issue=9 |pages=1064–6 |date=November 2001 |pmid=11704015 |doi=10.1016/s0002-9149(01)01996-8 |url=}}</ref> represents no [[microvascular disease]]. The hemodynamic significant abnormality is concluded with the presence of spectral broadening and increased velocity on [[USG]].
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''6.''' The performance of diagnostic studies to identify clinically significant RAS is indicated in patients with sudden, unexplained pulmonary edema (especially in azotemic patients). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


{|class="wikitable"
[[Reno aortic velocity]] ratio > 3.5 corresponds with 60% [[stenosis]]<ref name="pmid7741367">{{cite journal |vauthors=Olin JW, Piedmonte MR, Young JR, DeAnna S, Grubb M, Childs MB |title=The utility of duplex ultrasound scanning of the renal arteries for diagnosing significant renal artery stenosis |journal=Ann Intern Med |volume=122 |issue=11 |pages=833–8 |date=June 1995 |pmid=7741367 |doi=10.7326/0003-4819-122-11-199506010-00004 |url=}}</ref> and RAPSV (Renal artery peak systolic velocity) greater than 150cm/s corresponds to 50% stenosis whereas velocity greater than 180cm/s  corresponds to 60% stenosis<ref name="pmid7741367">{{cite journal |vauthors=Olin JW, Piedmonte MR, Young JR, DeAnna S, Grubb M, Childs MB |title=The utility of duplex ultrasound scanning of the renal arteries for diagnosing significant renal artery stenosis |journal=Ann Intern Med |volume=122 |issue=11 |pages=833–8 |date=June 1995 |pmid=7741367 |doi=10.7326/0003-4819-122-11-199506010-00004 |url=}}</ref><ref name="pmid7569132">{{cite journal |vauthors=Hélénon O, el Rody F, Correas JM, Melki P, Chauveau D, Chrétien Y, Moreau JF |title=Color Doppler US of renovascular disease in native kidneys |journal=Radiographics |volume=15 |issue=4 |pages=833–54; discussion 854–65 |date=July 1995 |pmid=7569132 |doi=10.1148/radiographics.15.4.7569132 |url=}}</ref>. According to recent studies, the [[sensitivity]] and [[specificity]] of [[ultrasound-guided]] detection of [[renal artery stenosis]] are usually 85% and 92% respectively. Severe [[stenosis]] is diagnosed on [[USG]] with slowed [[systolic accelerations]] along with the decreased [[resistive index]]<ref name="pmid1620853">{{cite journal |vauthors=Stavros AT, Parker SH, Yakes WF, Chantelois AE, Burke BJ, Meyers PR, Schenck JJ |title=Segmental stenosis of the renal artery: pattern recognition of tardus and parvus abnormalities with duplex sonography |journal=Radiology |volume=184 |issue=2 |pages=487–92 |date=August 1992 |pmid=1620853 |doi=10.1148/radiology.184.2.1620853 |url=}}</ref>.
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class IIa]]


|-
[[Quantitative]] criteria for diagnosing distal [[stenosis]] includes early peak [[systolic]] acceleration <3m/s2, an acceleration index > 4m/s2, and or greater than 5% difference in [[RRI]] between both the [[kidneys]]. Because these waveforms are difficult to interpret these criteria are difficult to interpret<ref name="pmid12823921">{{cite journal |vauthors=Conkbayir I, Yücesoy C, Edgüer T, Yanik B, Yaşar Ayaz U, Hekimoğlu B |title=Doppler sonography in renal artery stenosis. An evaluation of intrarenal and extrarenal imaging parameters |journal=Clin Imaging |volume=27 |issue=4 |pages=256–60 |date=2003 |pmid=12823921 |doi=10.1016/s0899-7071(02)00547-8 |url=}}</ref><ref name="pmid8983584">{{cite journal |vauthors=Baxter GM, Aitchison F, Sheppard D, Moss JG, McLeod MJ, Harden PN, Love JG, Robertson M, Taylor G |title=Colour Doppler ultrasound in renal artery stenosis: intrarenal waveform analysis |journal=Br J Radiol |volume=69 |issue=825 |pages=810–5 |date=September 1996 |pmid=8983584 |doi=10.1259/0007-1285-69-825-810 |url=}}</ref>.
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' The performance of diagnostic studies to identify clinically significant RAS is reasonable in patients with unexplained renal failure, including individuals starting renal replacement therapy (dialysis or renal transplantation). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


{|class="wikitable"
===<u>Computed Tomographic Angiography.</u>===
|-
[[CT angiography]] provides a three-dimensional assessment of the tissue as one of the important tools in the diagnosis of [[Renal artery stenosis]].
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class IIb]]


|-
*Contraindicated in patients with [[contrast allergy]] as this procedure modality involves the [[ionizing radiations]] and [[iodinated]] [[contrast]] medium.
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' The performance of arteriography to identify significant RAS may be reasonable in patients with multivessel coronary artery disease and none of the clinical clues (Figure 17) or PAD at the time of arteriography. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
*In [[patients]] having underlying [[renal impairment]] the use of [[iodinated contrast]] can lead to the development of [[contrast-induced nephropathy]], but it can be prevented with the use of [[hydration]] before doing the procedure.
*The [[sensitivity]] of this procedure is extremely high with 94% and [[specificity]] varies between 60% to 90 %<ref name="pmid17050355">{{cite journal |vauthors=Eklöf H, Ahlström H, Magnusson A, Andersson LG, Andrén B, Hägg A, Bergqvist D, Nyman R |title=A prospective comparison of duplex ultrasonography, captopril renography, MRA, and CTA in assessing renal artery stenosis |journal=Acta Radiol |volume=47 |issue=8 |pages=764–74 |date=October 2006 |pmid=17050355 |doi=10.1080/02841850600849092 |url=}}</ref><ref name="pmid17497443">{{cite journal |vauthors=Rountas C, Vlychou M, Vassiou K, Liakopoulos V, Kapsalaki E, Koukoulis G, Fezoulidis IV, Stefanidis I |title=Imaging modalities for renal artery stenosis in suspected renovascular hypertension: prospective intraindividual comparison of color Doppler US, CT angiography, GD-enhanced MR angiography, and digital substraction angiography |journal=Ren Fail |volume=29 |issue=3 |pages=295–302 |date=2007 |pmid=17497443 |doi=10.1080/08860220601166305 |url=}}</ref>.
*[[CTA]] can give the detailed resolution of even small [[accessory renal arteries]].
*It is also the diagnostic modality of choice in patients having limited capacity to hold breath and also in patients having [[claustrophobia]].
*At the same time, [[CTA]] is having limited diagnostic modality as compared to [[MRA]] in detecting clinically significant [[Renal artery stenosis]] and also in patients having [[renal]] dysfunction<br />


|-
===<u>Magnetic Resonance Angiography</u>===
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' The performance of diagnostic studies to identify clinically significant RAS may be reasonable in patients with unexplained congestive heart failure or refractory angina (see Section 3.5.2.4). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
[[MRA]] is having [[sensitivity]] and [[specificity]] of 90-100%<ref name="pmid17050355">{{cite journal |vauthors=Eklöf H, Ahlström H, Magnusson A, Andersson LG, Andrén B, Hägg A, Bergqvist D, Nyman R |title=A prospective comparison of duplex ultrasonography, captopril renography, MRA, and CTA in assessing renal artery stenosis |journal=Acta Radiol |volume=47 |issue=8 |pages=764–74 |date=October 2006 |pmid=17050355 |doi=10.1080/02841850600849092 |url=}}</ref><ref name="pmid17497443">{{cite journal |vauthors=Rountas C, Vlychou M, Vassiou K, Liakopoulos V, Kapsalaki E, Koukoulis G, Fezoulidis IV, Stefanidis I |title=Imaging modalities for renal artery stenosis in suspected renovascular hypertension: prospective intraindividual comparison of color Doppler US, CT angiography, GD-enhanced MR angiography, and digital substraction angiography |journal=Ren Fail |volume=29 |issue=3 |pages=295–302 |date=2007 |pmid=17497443 |doi=10.1080/08860220601166305 |url=}}</ref>  
|}


==2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)-Recommendations for Diagnostic Methods to Diagnose RAS (DO NOT EDIT)<ref name="pmid16549646">{{cite journal |author=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 |title=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 |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>==
*This procedure does not involve the use of [[iodinated contrast]] or [[radiations]], unlike [[CTA]].
*In patients with intermediate to [[end-stage renal failure]] due to the risk of [[nephrogenic]] systemic [[fibrosis]], [[gadolinium-based contrast media]] should be avoided.
*Additionally, In patients with the kind of implanted devices (i.e., [[pacemakers]], [[defibrillators]], [[cochlear implants]], and [[spinal cord stimulators]]), or in [[claustrophobic]] patients, [[MRA]] should not be used.
*[[Contrast]] reaction associated with [[MRA]] is lower as compared to [[CTA]]


{|class="wikitable"
===<u>Angiography</u>===
|-
Invasive [[renal arteriography]] is an important helpful modality used these days in evaluating [[Renal artery stenosis]].
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class I]]


|-
*[[Angiography]] can detect intrarenal [[vascular]] abnormalities and [[anatomical]] abnormalities of the [[kidneys]], [[renal arteries]], and [[aorta]], in addition to evaluating the severity of [[RAS]].
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Duplex ultrasonography is recommended as a screening test to establish the diagnosis of RAS. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
*[[Digital angiography]] by subtraction increases contrast resolution and can minimize the amount of [[contrast]] required to as little as 15mL.
*There are risks involved with [[arterial puncture]] and catheter/wire stimulation because [[renal angiography]] is invasive, which may lead to [[arterial damage]], [[spasm]], or [[thromboembolic phenomena]]<ref name="pmid7500898">{{cite journal |vauthors=Thadhani RI, Camargo CA, Xavier RJ, Fang LS, Bazari H |title=Atheroembolic renal failure after invasive procedures. Natural history based on 52 histologically proven cases |journal=Medicine (Baltimore) |volume=74 |issue=6 |pages=350–8 |date=November 1995 |pmid=7500898 |doi=10.1097/00005792-199511000-00005 |url=}}</ref>.
*[[Carbon dioxide]] should be used as a [[non-nephrotoxic]] [[contrast]] agent in patients with [[renal failure]] or [[contrast allergy]].
*To assess hemodynamic importance before conducting therapeutic procedures such as [[percutaneous transluminal renal angioplasty]] (PTRA) or stenting, translesional pressure gradients may be measured across regions of [[stenosis]].


|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Computed tomographic angiography (in individuals with normal renal function) is recommended as ascreening test to establish the diagnosis of RAS. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Magnetic resonance angiography is recommended as a screening test to establish the diagnosis of RAS. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' When the clinical index of suspicion is high and the results of noninvasive tests are inconclusive, catheter angiography is recommended as a diagnostic test to establish the diagnosis of RAS. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class III]]
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Captopril renal scintigraphy is not recommended as a screening test to establish the diagnosis of RAS. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.''' Selective renal vein renin measurements are not recommended as a useful screening test to establish the diagnosis of RAS. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''3.''' Plasma renin activity is not recommended as a useful screening test to establish the diagnosis of RAS. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''4.''' The captopril test (measurement of plasma renin activity after captopril administration) is not recommended as a useful screening test to establish the diagnosis of RAS. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


==References==
==References==
 
<references />
{{Reflist|2}}
 
[[Category:Kidney diseases]]
[[Category:Nephrology]]
[[Category:Cardiology]]
 
{{WH}}
{{WS}}

Latest revision as of 23:04, 13 December 2020

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

Overview

There are numerous tests and procedures involved in the detection of renal artery stenosis. Renal artery stenosis is best diagnosed with MRA(Magnetic resonance Imaging), Doppler ultrasound, Computed tomography, renal scintigraphy, peripheral renin levels, and renal vein sampling. Though these all modalities are used for making the diagnosis but still renal vein sampling, renal scintigraphy is not the first choice for making the diagnosis of renal artery stenosis because of their low sensitivity and specificity which is around 38-40.

Diagnosis

There are numerous tests and procedures involved in the detection of renal artery stenosis. Renal artery stenosis is best diagnosed with MRA(Magnetic resonance Imaging), Doppler ultrasound, Computed tomography, renal scintigraphy, peripheral renin levels, and renal vein sampling. Though these all modalities are used for making the diagnosis but still renal vein sampling, renal scintigraphy are not the first choice for making the diagnosis of renal artery stenosis because of their low sensitivity and specificity[1][2] which is around 38-40.

The imaging modalities may be considered diagnostic if the following objectives are met:

(1) Anatomic and or Hemodynamic abnormality

(2) Anatomic consequences and complications associated with renal artery stenosis (Post stenotic dilatation of renal artery can be seen with the use of CTA and MRA, shrinkage of renal parenchyma, with kidneys being < 8 cm.

(3) Functional and cellular consequences of renal artery stenosis

(4) Renal impairment criteria related to renovascular disease should be me[3].

Ultrasonography

Ultrasonography is readily available, secure, and inexpensive, and consequently is usually the first imaging study used to detect Renal artery stenosis. Usually, the results and accuracy are operator dependent and range in between 60-90%[4]. This modality helps in the assessment of

A renal artery EDV >90cm/s[5] and RRI< 75-80[6] represents no microvascular disease. The hemodynamic significant abnormality is concluded with the presence of spectral broadening and increased velocity on USG.

Reno aortic velocity ratio > 3.5 corresponds with 60% stenosis[7] and RAPSV (Renal artery peak systolic velocity) greater than 150cm/s corresponds to 50% stenosis whereas velocity greater than 180cm/s corresponds to 60% stenosis[7][8]. According to recent studies, the sensitivity and specificity of ultrasound-guided detection of renal artery stenosis are usually 85% and 92% respectively. Severe stenosis is diagnosed on USG with slowed systolic accelerations along with the decreased resistive index[9].

Quantitative criteria for diagnosing distal stenosis includes early peak systolic acceleration <3m/s2, an acceleration index > 4m/s2, and or greater than 5% difference in RRI between both the kidneys. Because these waveforms are difficult to interpret these criteria are difficult to interpret[10][11].

Computed Tomographic Angiography.

CT angiography provides a three-dimensional assessment of the tissue as one of the important tools in the diagnosis of Renal artery stenosis.

Magnetic Resonance Angiography

MRA is having sensitivity and specificity of 90-100%[12][13]

Angiography

Invasive renal arteriography is an important helpful modality used these days in evaluating Renal artery stenosis.


References

  1. ↑ Napoli V, Pinto S, Bargellini I, Vignali C, Cioni R, Petruzzi P, Salvetti A, Bartolozzi C (April 2002). "Duplex ultrasonographic study of the renal arteries before and after renal artery stenting". Eur Radiol. 12 (4): 796–803. doi:10.1007/s003300101121. PMID 11960229.
  2. ↑ Grenier N, Trillaud H, Combe C, Degrèze P, Jeandot R, Gosse P, Douws C, Palussière J (April 1996). "Diagnosis of renovascular hypertension: feasibility of captopril-sensitized dynamic MR imaging and comparison with captopril scintigraphy". AJR Am J Roentgenol. 166 (4): 835–43. doi:10.2214/ajr.166.4.8610560. PMID 8610560.
  3. ↑ Grenier N, Hauger O, Cimpean A, Pérot V (January 2006). "Update of renal imaging". Semin Nucl Med. 36 (1): 3–15. doi:10.1053/j.semnuclmed.2005.08.001. PMID 16356793.
  4. ↑ Zhang HL, Sos TA, Winchester PA, Gao J, Prince MR (2009). "Renal artery stenosis: imaging options, pitfalls, and concerns". Prog Cardiovasc Dis. 52 (3): 209–19. doi:10.1016/j.pcad.2009.10.003. PMID 19917332.
  5. ↑ Radermacher J, Chavan A, Bleck J, Vitzthum A, Stoess B, Gebel MJ, Galanski M, Koch KM, Haller H (February 2001). "Use of Doppler ultrasonography to predict the outcome of therapy for renal-artery stenosis". N Engl J Med. 344 (6): 410–7. doi:10.1056/NEJM200102083440603. PMID 11172177.
  6. ↑ Mukherjee D, Bhatt DL, Robbins M, Roffi M, Cho L, Reginelli J, Bajzer C, Navarro F, Yadav JS (November 2001). "Renal artery end-diastolic velocity and renal artery resistance index as predictors of outcome after renal stenting". Am J Cardiol. 88 (9): 1064–6. doi:10.1016/s0002-9149(01)01996-8. PMID 11704015.
  7. ↑ 7.0 7.1 Olin JW, Piedmonte MR, Young JR, DeAnna S, Grubb M, Childs MB (June 1995). "The utility of duplex ultrasound scanning of the renal arteries for diagnosing significant renal artery stenosis". Ann Intern Med. 122 (11): 833–8. doi:10.7326/0003-4819-122-11-199506010-00004. PMID 7741367.
  8. ↑ Hélénon O, el Rody F, Correas JM, Melki P, Chauveau D, Chrétien Y, Moreau JF (July 1995). "Color Doppler US of renovascular disease in native kidneys". Radiographics. 15 (4): 833–54, discussion 854–65. doi:10.1148/radiographics.15.4.7569132. PMID 7569132.
  9. ↑ Stavros AT, Parker SH, Yakes WF, Chantelois AE, Burke BJ, Meyers PR, Schenck JJ (August 1992). "Segmental stenosis of the renal artery: pattern recognition of tardus and parvus abnormalities with duplex sonography". Radiology. 184 (2): 487–92. doi:10.1148/radiology.184.2.1620853. PMID 1620853.
  10. ↑ Conkbayir I, Yücesoy C, Edgüer T, Yanik B, Yaşar Ayaz U, Hekimoğlu B (2003). "Doppler sonography in renal artery stenosis. An evaluation of intrarenal and extrarenal imaging parameters". Clin Imaging. 27 (4): 256–60. doi:10.1016/s0899-7071(02)00547-8. PMID 12823921.
  11. ↑ Baxter GM, Aitchison F, Sheppard D, Moss JG, McLeod MJ, Harden PN, Love JG, Robertson M, Taylor G (September 1996). "Colour Doppler ultrasound in renal artery stenosis: intrarenal waveform analysis". Br J Radiol. 69 (825): 810–5. doi:10.1259/0007-1285-69-825-810. PMID 8983584.
  12. ↑ 12.0 12.1 Eklöf H, Ahlström H, Magnusson A, Andersson LG, Andrén B, Hägg A, Bergqvist D, Nyman R (October 2006). "A prospective comparison of duplex ultrasonography, captopril renography, MRA, and CTA in assessing renal artery stenosis". Acta Radiol. 47 (8): 764–74. doi:10.1080/02841850600849092. PMID 17050355.
  13. ↑ 13.0 13.1 Rountas C, Vlychou M, Vassiou K, Liakopoulos V, Kapsalaki E, Koukoulis G, Fezoulidis IV, Stefanidis I (2007). "Imaging modalities for renal artery stenosis in suspected renovascular hypertension: prospective intraindividual comparison of color Doppler US, CT angiography, GD-enhanced MR angiography, and digital substraction angiography". Ren Fail. 29 (3): 295–302. doi:10.1080/08860220601166305. PMID 17497443.
  14. ↑ Thadhani RI, Camargo CA, Xavier RJ, Fang LS, Bazari H (November 1995). "Atheroembolic renal failure after invasive procedures. Natural history based on 52 histologically proven cases". Medicine (Baltimore). 74 (6): 350–8. doi:10.1097/00005792-199511000-00005. PMID 7500898.
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