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| __NOTOC__ | | __NOTOC__ |
| | {{Renal artery stenosis}} |
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| | [[File:Siren.gif|30px|link=Renal artery stenosis resident survival guide]]|| <br> || <br>
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| | [[Renal artery stenosis resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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| {{Renal artery stenosis}}
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| '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' | | {{CMG}}; '''Associate Editor-In-Chief:''' {{Shivam Singla}} |
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| {{CMG}}; '''Associate Editor-In-Chief:''' [[User:YazanDaaboul|Yazan Daaboul]], [[User:Sergekorjian|Serge Korjian]]
| | {{SK}} RAS; renovascular hypertension; atherosclerotic renal artery stenosis; ARAS |
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| {{SK}}: RAS, atherosclerotic renal artery stenosis, ARAS | |
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| ==[[Renal artery stenosis overview|Overview]]== | | ==[[Renal artery stenosis overview|Overview]]== |
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| ==[[Renal artery stenosis causes|Causes]]== | | ==[[Renal artery stenosis causes|Causes]]== |
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| ==Classification== | | ==[[Renal artery stenosis classification|Classification]]== |
| Renal artery stenosis may be classified according to whether there is unilateral or bilateral involvement of the renal arteries. Additionally, renal artery stenosis is often classified anatomically according to severity of luminal narrowing. The following criteria are used according to most published studies about ARAS.<ref name="pmid8234704">{{cite journal| author=Kliewer MA, Tupler RH, Carroll BA, Paine SS, Kriegshauser JS, Hertzberg BS et al.| title=Renal artery stenosis: analysis of Doppler waveform parameters and tardus-parvus pattern. | journal=Radiology | year= 1993 | volume= 189 | issue= 3 | pages= 779-87 | pmid=8234704 | doi=10.1148/radiology.189.3.8234704 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8234704 }} </ref><ref name="pmid2243982">{{cite journal| author=Desberg AL, Paushter DM, Lammert GK, Hale JC, Troy RB, Novick AC et al.| title=Renal artery stenosis: evaluation with color Doppler flow imaging. | journal=Radiology | year= 1990 | volume= 177 | issue= 3 | pages= 749-53 | pmid=2243982 | doi=10.1148/radiology.177.3.2243982 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2243982 }} </ref>
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| {|border="1" style="border-collapse:collapse; text-align:center; font-size:120%;" cellpadding="5" align="center" width="300px"
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| | bgcolor="#ff9a69" align="center"|'''Severity'''||bgcolor="#ff9a69" align="center"|'''Luminal Narrowing'''
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| | bgcolor="#f3f3f3"| Normal
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| | 0%
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| |bgcolor="#f3f3f3"| Mild
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| | 1-49%
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| | bgcolor="#f3f3f3"| Moderate
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| | 50-69%
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| | bgcolor="#f3f3f3"| Severe
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| | 70-99%
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| |-
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| | bgcolor="#f3f3f3"| Occluded
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| | 100%
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| |}
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| To note, some studies have different classification criteria than those listed above, with "mild disease" starting after 50% of luminal narrowing. Such classification remains coherent with the definition of ARAS as narrowing > 50%.<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>
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| Another classification is based on hemodynamic function in RAS. This classification simply differentiates between hemodynamically insignificant RAS (< 75% stenosis) and hemodynamically significant RAS (> 75% stenosis).<ref name="pmid15114537">{{cite journal| author=Kidney Disease Outcomes Quality Initiative (K/DOQI)| title=K/DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease. | journal=Am J Kidney Dis | year= 2004 | volume= 43 | issue= 5 Suppl 1 | pages= S1-290 | pmid=15114537 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15114537 }} </ref>
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| ==[[Renal artery stenosis epidemiology and demographics|Epidemiology and Demographics]]== | | ==[[Renal artery stenosis epidemiology and demographics|Epidemiology and Demographics]]== |
| Atherosclerotic renal artery stenosis (ARAS) is considered a disease of the elderly. The true prevalence of ARAS has not been reliably determined and prevalence rates present so far may in fact be an underestimate or an overestimate of the true prevalence due to the varying selection criteria in different studies. The prevalence of ARAS increases substantially among patients with cardiovascular co-morbidities, such as diabetes mellitus, dyslipidemia, essential hypertension, and known coronary or peripheral artery disease.
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| ==[[Renal artery stenosis risk factors|Risk Factors]]== | | ==[[Renal artery stenosis risk factors|Risk Factors]]== |
| Risk factors for ARAS, per se, are poorly studied. The most commonly associated risk factors are those similar for other types of atherosclerosis, such as advanced age, dyslipidemia, diabetes mellitus, smoking, and hypertension.
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| ==Diagnosis== | | ==Diagnosis== |
| Non-invasive diagnosis is the first line for screening of ARAS. Doppler ultrasonography, CTA, and MRA may all be used to diagnose ARAS. Invasive diagnostic technique, such as renal angiography, is considered the gold standard for diagnosis and may be used when concomitant catheterizations are needed or when previously performed non-invasive techniques yielded equivocal results.
| | [[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]] |
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| [[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]] | [[Renal artery stenosis other imaging findings|Other Imaging Findings]] | [[Renal artery stenosis other diagnostic studies|Other Diagnostic Studies]] | |
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| ==Treatment== | | ==Treatment== |
| Medical therapy is considered the first line of management for patients with ARAS. Several anti-hypertensive medications have proven to be efficacious in ARAS patients. According to the 2013 ACC/AHA Guidelines for the Management of PAD, ACE-I and CCB may be used in patients with RAS because they have effect on both lowering BP and delaying renal disease. Other blood pressure lowering medications include beta-blockers, hydrazine, and chlorothiazide. Although ARBs may be used as well, they still have level B evidence for use in ARAS because trials have not been conducted on the use of ARBs in such patients.
| | [[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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| Angioplasty and stent implantation were previously recommended by the 2013 ACC/AHA Guidelines. However, emerging data from the CORAL trial showed that although there are high technical success rates with angioplasty/stenting, the clinical end points are inconsistently and modestly modified. Therefore, raising the suspicion that PRI (percutaneous renal interventions) can incur in substantial costs without a significant public health advantage<ref name="pmid24245566">{{cite journal| author=Cooper CJ, Murphy TP, Cutlip DE, Jamerson K, Henrich W, Reid DM et al.| title=Stenting and medical therapy for atherosclerotic renal-artery stenosis. | journal=N Engl J Med | year= 2014 | volume= 370 | issue= 1 | pages= 13-22 | pmid=24245566 |doi=10.1056/NEJMoa1310753 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24245566 }}</ref>
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| Vascular reconstruction of the renal arteries may be indicated in a small minority of patients. However, surgical reconstruction is associated with complications and carries a 5-15% for surgical re-intervention.
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| [[Renal artery stenosis medical therapy|Medical Therapy]] | [[Renal artery stenosis angioplasty and stenting|Angioplasty and Stenting]] | [[Renal artery stenosis surgery|Surgery]] | [[Renal artery stenosis primary prevention|Primary Prevention]] | [[Renal artery stenosis secondary prevention|Secondary Prevention]] | [[Renal artery stenosis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Renal artery stenosis future or investigational therapies|Future or Investigational Therapies]] | |
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| ==Case Studies== | | ==Case Studies== |
| *[[Renal artery stenosis case study one|Case #1]]
| | [[Renal artery stenosis case study one|Case #1]] |
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| ==Related Chapters==
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| * [[Renovascular hypertension]]
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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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| ==External Links==
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| *[http://www.youtube.com/watch?v=xeV3lmYi1Hk Bilateral Renal Artery Stenosis example]
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| *[http://www.youtube.com/watch?v=4UzLFatOg1Q Right Renal Artery Stenosis example]
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| *Bilateral Renal Artery Stenosis
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| {{#ev:youtube|xeV3lmYi1Hk}}
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| * Right Renal Artery Stenosis
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| {{#ev:youtube|4UzLFatOg1Q}}
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| {{Circulatory system pathology}}
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| {{Nephrology}}
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| ==References== | | ==References== |