Renal artery stenosis diagnostic criteria
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yazan Daaboul,Serge Korjian
Overview
Several clinical clues aid in the suspicion of ARAS and warrant further investigation. To date, imaging is considered the optimal modality to diagnose ARAS. According to the ACC/AHA guidelines in 2011, Doppler ultrasonography, CT angiography, and MR angiography are all non-invasive techniques to diagnose ARAS. Renal angiography remains the gold standard for diagnosis of ARAS. Nonethetheless, it is an invasive procedure that should be reserved to patients who are planning to perform a catheterization procedure and concede to renal angiography or to patients whose non-invasive imaging was equivocal.
Diagnosis
Indications for Work-Up
According to the 2011 ACC/AHA Guidelines for the Management of PAD[1], diagnostic work-up for renal artery stenosis is indicated in the following conditions:
Class I Recommendations[1]
- Hypertension of any stage before the age of 30
- Stage II hypertension in patients older than 55 years
- Accelerated condition of a previously controlled hypertension
- Resistant hypertension
- Malignant hypertension
- New azotemia after administration of ACE-I or ARB
- Unexplained atrophic kidney or asymmetric kidneys that differ by > 1.5 cm
- Sudden unexplained pulmonary edema
Class IIa Recommendations[1]
- Unexplained renal failure including patients starting renal replacement therapy
Class IIb Recommendations[1]
- Presence of multi vessel CAD and no clinical clues of ARAS or PAD
- Unexplained CHF or refractory angina
Diagnostic Methods[1]
The best technique to diagnose ARAS is by imaging. Assessment of both the main and the accessory renal arteries bilaterally is important for diagnostic purposes. Further evaluation should include the anatomic location of the stenosis, severity of stenosis, associated perirenal and perivascular pathologies, such as aneurysms or masses.[2] Duplex ultrasonography, computer tomographic angiography (CTA), magnetic resonance angiography (MRA), and catheter angiography are 4 techniques that are currently recommended for the diagnosis of ARAS.[2] In contrast, selective renal vein renin studies and captopril challenge testing are still not recommended.[2]
Duplex Ultrasonography
Diagnosis by Duplex ultrasonography is considered class I recommendation. It may be used as an initial screening tool for diagnosis of ARAS. Ultrasonography might not be very accurate in obese patients or those intestinal gas.[2]
Computed Tomographic Angiography
Diagnosis by CT angiography is considered class I recommendation. It provides higher spacial resolution compared to MRA. CT angiography may be used in patients with normal renal function to avoid contrast-induced nephropathy in patients with impaired renal function. Presence of previous stents or metallic objects are considered a contraindication for the use of CTA.[2]
Magnetic Resonance Angiography
Diagnosis by MRA is considered class I recommendation. Gadolinium-based MRA has less nephrotoxic characterstics with good visualization of the renal arteries and perirenal pathologies. Presence of previous stents or metallic objects are considered a contraindication for the use of MRA.[2]
Catheter Angiography
Catheter angiography is considered class I recommendation. It is the gold standard for the diagnosis of ARAS. Renal angiography may be used only if previous tests are equivocal and clinical suspicion is high or if the patient is already undergoing another catheterization process and concedes to renal angiography. Generally, it is associated with a low frequency of adverse events.[2]
2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic) (DO NOT EDIT)[3]
Clinical Clues to the Diagnosis of RAS (DO NOT EDIT)[3]
| Class I |
| "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. (Level of Evidence: B)" |
| "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. (Level of Evidence: B)" |
| "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). (Level of Evidence: C)" |
| "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). (Level of Evidence: B)" |
| "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. (Level of Evidence: B)" |
| "6. The performance of diagnostic studies to identify clinically significant RAS is indicated in patients with sudden, unexplained pulmonary edema (especially in azotemic patients). (Level of Evidence: B)" |
| Class IIa |
| "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). (Level of Evidence: B)" |
| Class IIb |
| "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. (Level of Evidence: B)" |
| "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). (Level of Evidence: C)" |
Diagnostic Methods (DO NOT EDIT)[3]
| Class I |
| "1. Duplex ultrasonography is recommended as a screening test to establish the diagnosis of RAS. (Level of Evidence: B)" |
| "2. Computed tomographic angiography (in individuals with normal renal function) is recommended as a screening test to establish the diagnosis of RAS. (Level of Evidence: B)" |
| "3. Magnetic resonance angiography is recommended as a screening test to establish the diagnosis of RAS. (Level of Evidence: B)" |
| "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. (Level of Evidence: B)" |
| Class III |
| "1. Captopril renal scintigraphy is not recommended as a screening test to establish the diagnosis of RAS. (Level of Evidence: C)" |
| "2. Selective renal vein renin measurements are not recommended as a useful screening test to establish the diagnosis of RAS. (Level of Evidence: B)" |
| "3. Plasma renin activity is not recommended as a useful screening test to establish the diagnosis of RAS. (Level of Evidence: B)" |
| "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. (Level of Evidence: B)" |
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK; et al. (2011). "2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 58 (19): 2020–45. doi:10.1016/j.jacc.2011.08.023. PMID 21963765.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL; et al. (2006). "ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary 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". J Am Coll Cardiol. 47 (6): 1239–312. doi:10.1016/j.jacc.2005.10.009. PMID 16545667.
- ↑ 3.0 3.1 3.2 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
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