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{{Short description|Kidney disease}}
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{{Infobox medical condition (new)
{{Use dmy dates|date=September 2024}}
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| name = Renal artery stenosis
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{{Infobox medical condition (new)
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| image = Kidney PioM.png
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| name = Renal artery stenosis
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| caption = {{Div col|style=text-align:left; font-size:smaller}}{{unbulleted list|1. [[Renal pyramid]] | 2. [[Interlobular artery]] | 3. [[Renal artery]] | 4. [[Renal vein]] | 5. [[Hilum of kidney|Renal hilum]] | 6. [[Renal pelvis]] | 7. [[Ureter]] | 8. [[Minor calyx]] | 9. [[Renal capsule]] | 10. [[Inferior renal capsule]] | 11. [[Superior renal capsule]] | 12. [[Interlobar vein]] | 13. [[Nephron]] | 14. [[Renal sinus]] | 15. [[Major calyx]] | 16. [[Renal papilla]] | 17. [[Renal column]]}}{{Div col end}}
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| image = Kidney PioM.png
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| caption = {{Div col|style=text-align:left; font-size:smaller}}{{unbulleted list|1. [[Renal pyramid]] | 2. [[Interlobular artery]] | 3. [[Renal artery]] | 4. [[Renal vein]] | 5. [[Hilum of kidney|Renal hilum]] | 6. [[Renal pelvis]] | 7. [[Ureter]] | 8. [[Minor calyx]] | 9. [[Renal capsule]] | 10. [[Inferior renal capsule]] | 11. [[Superior renal capsule]] | 12. [[Interlobar vein]] | 13. [[Nephron]] | 14. [[Renal sinus]] | 15. [[Major calyx]] | 16. [[Renal papilla]] | 17. [[Renal column]]}}{{Div col end}}
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| risks = Smoking, High blood pressure<ref name=NIH2015/>
| risks = Smoking, High blood pressure<ref name=NIH2015/>
| diagnosis = Captopril challenge test, Doppler ultrasound<ref name=dop/><ref name=cli/>
| diagnosis = Captopril challenge test, Doppler ultrasound<ref name="Granata Fiorini Andrulli et al 2009"/><ref name=cli/>
| differential =
| differential =
| prevention =
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| treatment = ACE inhibitors<ref name=NIH2015/>
| treatment = ACE inhibitors<ref name=NIH2015/>
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| field = [[Nephrology]]
| field = [[Nephrology]]
}}
}}


'''Renal artery stenosis''' ('''RAS''') is the [[stenosis|narrowing]] of one or both of the [[renal artery|renal arteries]], most often caused by [[atherosclerosis]] or [[fibromuscular dysplasia]]. This narrowing of the renal artery can impede [[blood flow]] to the target [[kidney]], resulting in [[renovascular hypertension]] – a secondary type of [[hypertension|high blood pressure]]. Possible complications of renal artery stenosis are [[chronic kidney disease]] and [[coronary artery disease]].<ref name="NIH2015">{{Cite web|url=http://www.niddk.nih.gov/health-information/health-topics/kidney-disease/renal-artery-stenosis-ras/Pages/facts.aspx |title=Renal Artery Stenosis |website=[[National Institute of Diabetes and Digestive and Kidney Diseases]] |accessdate=2015-08-17}}</ref>
'''Renal artery stenosis''' ('''RAS''') is the [[stenosis|narrowing]] of one or both of the [[renal artery|renal arteries]], most often caused by [[atherosclerosis]] or [[fibromuscular dysplasia]]. This narrowing of the renal artery can impede [[blood flow]] to the target [[kidney]], resulting in [[renovascular hypertension]] – a secondary type of [[hypertension|high blood pressure]]. Possible complications of renal artery stenosis are [[chronic kidney disease]] and [[coronary artery disease]].<ref name="NIH2015">{{Cite web |url=http://www.niddk.nih.gov/health-information/health-topics/kidney-disease/renal-artery-stenosis-ras/Pages/facts.aspx |title=Renal Artery Stenosis |website=[[National Institute of Diabetes and Digestive and Kidney Diseases]] |access-date=17 August 2015 |archive-date=16 December 2016 |archive-url=https://web.archive.org/web/20161216003304/https://www.niddk.nih.gov/health-information/health-topics/kidney-disease/renal-artery-stenosis-ras/Pages/facts.aspx |url-status=dead }}</ref>


==Signs and symptoms==
==Signs and symptoms==
Most cases of renal artery stenosis are asymptomatic, and the main problem is high blood pressure that cannot be controlled with medication.<ref>{{Cite web|title = Renovascular hypertension: MedlinePlus Medical Encyclopedia|url = https://www.nlm.nih.gov/medlineplus/ency/article/000204.htm|website = www.nlm.nih.gov|accessdate = 2015-08-17}}</ref> Decreased [[kidney function]] may develop if both kidneys do not receive adequate blood flow, furthermore some people with renal artery stenosis present with episodes of [[flash pulmonary edema]].<ref>{{Cite journal|title = Flash pulmonary oedema and bilateral renal artery stenosis: the Pickering Syndrome|url = http://eurheartj.oxfordjournals.org/content/early/2011/03/14/eurheartj.ehr056|journal = European Heart Journal|date = 2011-03-15|issn = 0195-668X|pmid = 21406441|pages = 2231–5|doi = 10.1093/eurheartj/ehr056|first = Franz H.|last = Messerli|first2 = Sripal|last2 = Bangalore|first3 = Harikrishna|last3 = Makani|first4 = Stefano F.|last4 = Rimoldi|first5 = Yves|last5 = Allemann|first6 = Christopher J.|last6 = White|first7 = Stephen|last7 = Textor|first8 = Peter|last8 = Sleight|volume=32|issue = 18|doi-access = free}}</ref>
Most cases of renal artery stenosis are asymptomatic, and the main problem is high blood pressure that cannot be controlled with medication.<ref>{{MedlinePlusEncyclopedia|000204|Renovascular hypertension}}</ref> Decreased [[kidney function]] may develop if both kidneys do not receive adequate blood flow, furthermore some people with renal artery stenosis present with episodes of [[flash pulmonary edema]].<ref>{{cite journal |last1=Messerli |first1=F. H. |last2=Bangalore |first2=S. |last3=Makani |first3=H. |last4=Rimoldi |first4=S. F. |last5=Allemann |first5=Y. |last6=White |first6=C. J. |last7=Textor |first7=S. |last8=Sleight |first8=P. |title=Flash pulmonary oedema and bilateral renal artery stenosis: the Pickering Syndrome |journal=European Heart Journal |date=2 September 2011 |volume=32 |issue=18 |pages=2231–2235 |doi=10.1093/eurheartj/ehr056 |pmid=21406441 |doi-access=free }}</ref>


==Cause==
==Cause==
Renal artery stenosis is most often caused by atherosclerosis which causes the renal arteries to harden and narrow due to the build-up of [[atherosclerosis|plaque]]. This is known as atherosclerotic renovascular disease, which accounts for about 90% of cases.<ref>{{cite journal |last1=Vassallo |first1=Diana |last2=Kalra |first2=Philip A. |title=Atherosclerotic renovascular disease – epidemiology, treatment and current challenges |journal=Advances in Interventional Cardiology |date=2017 |volume=3 |issue=3 |pages=191–201 |doi=10.5114/aic.2017.70186 |pmid=29056991 |pmc=5644037 }}</ref> This narrowing of renal arteries due to plaque build-up leads to higher blood pressure within the artery and decreased blood flow to the kidney. This decreased blood flow leads to decreased blood pressure in the kidney, which leads to the activation of the Renin-Angiotensin-Aldosterone (RAA) system. Juxtaglomerular cells secrete renin, which converts angiotensinogen to angiotensin I, which is then converted to angiotensin II by angiotensin converting enzyme (ACE). Angiotensin II then acts on the adrenal cortex to increase secretion of the hormone aldosterone. Aldosterone causes sodium and water retention, leading to an increase in blood volume and blood pressure. Therefore, people with RAS have chronic high blood pressure because their RAA system is hyperactivated.<ref>{{cite journal |last1=Safian |first1=Robert D. |title=Renal artery stenosis |journal=Progress in Cardiovascular Diseases |date=March 2021 |volume=65 |pages=60–70 |doi=10.1016/j.pcad.2021.03.003 |pmid=33745915 |s2cid=232311595 }}</ref>
Renal artery stenosis is most often caused by atherosclerosis which causes the renal arteries to harden and narrow due to the build-up of [[atherosclerosis|plaque]]. This is known as atherosclerotic renovascular disease.{{citation needed|date=April 2018}}This accounts for about 90% of cases with most of the rest due to [[fibromuscular dysplasia]].<ref>{{cite web|title=RenalArtery Stenosis|url=https://www.niddk.nih.gov/health-information/health-topics/kidney-disease/renal-artery-stenosis-ras/Documents/RenalArteryStenosis_508.pdf|website=NIH|publisher=National Institute of Health|accessdate=1 August 2016}}</ref> Fibromuscular dysplasia is the predominant cause in young patients, usually females under 40 years of age.<ref>{{Cite journal|title = Fibromuscular Dysplasia: Practice Essentials, Background, Pathophysiology|url = http://emedicine.medscape.com/article/1161248-overview#a6|date = 2018-09-19}}</ref>


==Pathophysiology==
==Pathophysiology==
The pathophysiology of renal artery stenosis leads to changes in the structure of the kidney that are most noticeable in the [[renal tubule|tubular tissue]].<ref name="Renal2015">{{Cite journal|title = Renal Artery Stenosis: Background, Pathophysiology, Etiology|url = http://emedicine.medscape.com/article/245023-overview#a5|date = 2018-12-14}}</ref> If the stenosis is [[chronic condition|longstanding]] and severe, the [[glomerular filtration rate]] in the affected kidneys never recovers and (prerenal) kidney failure is the result.{{medical citation needed|date=August 2015}}
The pathophysiology of renal artery stenosis leads to changes in the structure of the kidney that are most noticeable in the [[renal tubule|tubular tissue]].<ref name="Renal2015">{{EMedicine|article|245023|Renal Artery Stenosis}}</ref>


Changes include:<ref name=Renal2015/>
Changes include:<ref name=Renal2015/>
*[[Fibrosis]]
* [[Fibrosis]]
*[[Tubular cell]] size (decrease)
* [[Tubular cell]] size (decrease)
*Thickening of [[Bowman capsule]]
* Thickening of [[Bowman capsule]]
*Tubulosclerosis
* Tubulosclerosis
*Glomerular capillary tuft (atrophy)
* Glomerular capillary tuft (atrophy)


==Diagnosis==
==Diagnosis==
[[File:Assessment-of-the-kidneys-magnetic-resonance-angiography-perfusion-and-diffusion-1532-429X-13-70-S2.ogv|thumb|Assessment of Kidneys with Renal Artery Stenosis taken by Magnetic Resonance Angiography.|alt=]]
[[File:Assessment-of-the-kidneys-magnetic-resonance-angiography-perfusion-and-diffusion-1532-429X-13-70-S2.ogv|thumb|Assessment of Kidneys with Renal Artery Stenosis taken by Magnetic Resonance Angiography.|alt=]]
The diagnosis of renal artery stenosis can use many techniques to determine if the condition is present, a [[clinical prediction rule]] is available to guide diagnosis.<ref>{{Cite book|title = Clinical Prediction Models: A Practical Approach to Development, Validation, and Updating|url = https://books.google.com/?id=kHGK58cLsMIC&pg=PA12&dq=clinical+prediction+rule+is+used+in+renal+artery+stenosis#v=onepage&q=clinical%2520prediction%2520rule%2520is%2520used%2520in%2520renal%2520artery%2520stenosis&f=false|publisher = Springer Science & Business Media|date = 2008-12-16|isbn = 9780387772448|first = Ewout|last = Steyerberg}}</ref>
The diagnosis of renal artery stenosis can use many techniques to determine if the condition is present, a [[clinical prediction rule]] is available to guide diagnosis.<ref>{{Cite book|title = Clinical Prediction Models: A Practical Approach to Development, Validation, and Updating|url = https://books.google.com/books?id=kHGK58cLsMIC&q=clinical%2520prediction%2520rule%2520is%2520used%2520in%2520renal%2520artery%2520stenosis&pg=PA12|publisher = Springer Science & Business Media|date = 16 December 2008|isbn = 9780387772448|first = Ewout|last = Steyerberg|access-date = 28 October 2020|archive-date = 4 September 2024|archive-url = https://web.archive.org/web/20240904222703/https://books.google.com/books?id=kHGK58cLsMIC&q=clinical%2520prediction%2520rule%2520is%2520used%2520in%2520renal%2520artery%2520stenosis&pg=PA12#v=onepage&q=clinical%2520prediction%2520rule%2520is%2520used%2520in%2520renal%2520artery%2520stenosis&f=false|url-status = live}}</ref>


Among the diagnostic techniques are:
Among the diagnostic techniques are:
* Doppler ultrasound study of the kidneys<ref name="Granata Fiorini Andrulli et al 2009">{{cite journal |last1=Granata |first1=A. |last2=Fiorini |first2=F. |last3=Andrulli |first3=S. |last4=Logias |first4=F. |last5=Gallieni |first5=M. |last6=Romano |first6=G. |last7=Sicurezza |first7=E. |last8=Fiore |first8=C.E. |title=Doppler ultrasound and renal artery stenosis: An overview |journal=Journal of Ultrasound |date=December 2009 |volume=12 |issue=4 |pages=133–143 |doi=10.1016/j.jus.2009.09.006 |pmid=23397022 |pmc=3567456 }}</ref>
* Doppler ultrasound study of the kidneys<ref name="dop">{{Cite journal|title = Doppler ultrasound and renal artery stenosis: An overview|journal = Journal of Ultrasound|date = 2009-10-12|issn = 1971-3495|pmc = 3567456|pmid = 23397022|pages = 133–143|volume = 12|issue = 4|doi = 10.1016/j.jus.2009.09.006|first = A.|last = Granata|first2 = F.|last2 = Fiorini|first3 = S.|last3 = Andrulli|first4 = F.|last4 = Logias|first5 = M.|last5 = Gallieni|first6 = G.|last6 = Romano|first7 = E.|last7 = Sicurezza|first8 = C.E.|last8 = Fiore}}</ref>
* Refractory [[hypertension]]<ref>{{cite journal |last1=Protasiewicz |first1=Marcin |last2=Kądziela |first2=Jacek |last3=Początek |first3=Karol |last4=Poręba |first4=Rafał |last5=Podgórski |first5=Maciej |last6=Derkacz |first6=Arkadiusz |last7=Prejbisz |first7=Aleksander |last8=Mysiak |first8=Andrzej |last9=Januszewicz |first9=Andrzej |last10=Witkowski |first10=Adam |title=Renal Artery Stenosis in Patients With Resistant Hypertension |journal=The American Journal of Cardiology |date=November 2013 |volume=112 |issue=9 |pages=1417–1420 |doi=10.1016/j.amjcard.2013.06.030 |pmid=24135303 }}</ref>
* Refractory [[hypertension]]<ref>{{Cite journal|title = Renal artery stenosis in patients with resistant hypertension|journal = The American Journal of Cardiology|date = 2013-11-01|issn = 1879-1913|pmid = 24135303|pages = 1417–1420|volume = 112|issue = 9|doi = 10.1016/j.amjcard.2013.06.030|first = Marcin|last = Protasiewicz|first2 = Jacek|last2 = Kądziela|first3 = Karol|last3 = Początek|first4 = Rafał|last4 = Poręba|first5 = Maciej|last5 = Podgórski|first6 = Arkadiusz|last6 = Derkacz|first7 = Aleksander|last7 = Prejbisz|first8 = Andrzej|last8 = Mysiak|first9 = Andrzej|last9 = Januszewicz}}{{Subscription or libraries|sentence|via=[[ScienceDirect]]}}</ref>
* [[Auscultation]] (with [[stethoscope]]) - [[bruit]] ("rushing" sound)<ref>{{Cite book|title = Clinical Examination: A Systematic Guide to Physical Diagnosis|url = https://books.google.com/?id=cTFkBgAAQBAJ&pg=PA208&lpg=PA208&dq=costal+margin+auscultation+renal+artery+stenosis#v=onepage&q=costal%2520margin%2520auscultation%2520renal%2520artery%2520stenosis&f=false|publisher = Elsevier Health Sciences|date = 2013-09-20|isbn = 9780729541473|first = Nicholas Joseph|last = Talley|first2 = Simon|last2 = O'Connor}}</ref>
* [[Auscultation]] (with [[stethoscope]]) - [[bruit]] ("rushing" sound)<ref>{{Cite book|title = Clinical Examination: A Systematic Guide to Physical Diagnosis|url = https://books.google.com/books?id=cTFkBgAAQBAJ&q=costal%2520margin%2520auscultation%2520renal%2520artery%2520stenosis&pg=PA208|publisher = Elsevier Health Sciences|date = 20 September 2013|isbn = 9780729541473|first1 = Nicholas Joseph|last1 = Talley|first2 = Simon|last2 = O'Connor|access-date = 28 October 2020|archive-date = 4 September 2024|archive-url = https://web.archive.org/web/20240904222639/https://books.google.com/books?id=cTFkBgAAQBAJ&q=costal%2520margin%2520auscultation%2520renal%2520artery%2520stenosis&pg=PA208#v=onepage&q=costal%2520margin%2520auscultation%2520renal%2520artery%2520stenosis&f=false|url-status = live}}</ref>
* [[Captopril challenge test]]<ref name="cli">{{Cite book|title = A Clinical Approach to Medicine|url = https://books.google.com/?id=t0KmTrzxAlEC&pg=PA1243&lpg=PA1243&dq=captopril+challenge+test++renal+artery+stenosis#v=onepage&q=captopril%2520challenge%2520test%2520%2520renal%2520artery%2520stenosis&f=false|publisher = World Scientific|date = 2005-01-01|isbn = 9789812560735|first = Yong Yau|last = Ong}}</ref>
* [[Captopril challenge test]]<ref name="cli">{{Cite book|title = A Clinical Approach to Medicine|url = https://books.google.com/books?id=t0KmTrzxAlEC&q=captopril%2520challenge%2520test%2520%2520renal%2520artery%2520stenosis&pg=PA1243|publisher = World Scientific|date = 1 January 2005|isbn = 9789812560735|first = Yong Yau|last = Ong|access-date = 28 October 2020|archive-date = 4 September 2024|archive-url = https://web.archive.org/web/20240904222730/https://books.google.com/books?id=t0KmTrzxAlEC&q=captopril%2520challenge%2520test%2520%2520renal%2520artery%2520stenosis&pg=PA1243#v=onepage&q=captopril%2520challenge%2520test%2520%2520renal%2520artery%2520stenosis&f=false|url-status = live}}</ref>
* Captopril test dose effect on the differential renal function as measured by [[MAG3 scan]].{{medical citation needed|date=August 2015}}
* Captopril test dose effect on the differential renal function as measured by [[MAG3 scan]].<ref>{{cite journal |last1=Taylor |first1=Andrew T. |title=Radionuclides in Nephrourology, Part 2: Pitfalls and Diagnostic Applications |journal=Journal of Nuclear Medicine |date=May 2014 |volume=55 |issue=5 |pages=786–798 |doi=10.2967/jnumed.113.133454 |pmid=24591488 |pmc=4451959 }}</ref>
* Renal artery [[angiogram|arteriogram]].<ref>{{cite book |last= Sam |first= Amir H. |author2=James T.H. Teo |title= Rapid Medicine |publisher= [[Wiley-Blackwell]] |year= 2010 |isbn= 978-1405183239|title-link= Rapid Medicine }}</ref><ref>{{Cite journal|title = Assessment of the kidneys: magnetic resonance angiography, perfusion and diffusion|journal = Journal of Cardiovascular Magnetic Resonance|date = 2011-11-15|issn = 1532-429X|pmc = 3228749|pmid = 22085467|pages = 70|volume = 13|issue = 1|doi = 10.1186/1532-429X-13-70|first = Ulrike I.|last = Attenberger|first2 = John N.|last2 = Morelli|first3 = Stefan O.|last3 = Schoenberg|first4 = Henrik J.|last4 = Michaely}}</ref>
* Renal artery [[angiogram|arteriogram]].<ref>{{cite book |last= Sam |first= Amir H. |author2=James T.H. Teo |title= Rapid Medicine |publisher= [[Wiley-Blackwell]] |year= 2010 |isbn= 978-1405183239|title-link= Rapid Medicine }}</ref><ref>{{cite journal |last1=Attenberger |first1=Ulrike I |last2=Morelli |first2=John N |last3=Schoenberg |first3=Stefan O |last4=Michaely |first4=Henrik J |title=Assessment of the kidneys: magnetic resonance angiography, perfusion and diffusion |journal=Journal of Cardiovascular Magnetic Resonance |date=December 2011 |volume=13 |issue=1 |pages=70 |doi=10.1186/1532-429X-13-70 |pmid=22085467 |pmc=3228749 |doi-access=free }}</ref>


The specific criteria for renal artery stenosis on Doppler are an acceleration time of greater than 70 milliseconds, an acceleration index of less than 300 cm/sec² and a velocity ratio of the renal artery to aorta of greater than 3.5.<ref>{{cite journal |last1=Granata |first1=A. |last2=Fiorini |first2=F. |last3=Andrulli |first3=S. |last4=Logias |first4=F. |last5=Gallieni |first5=M. |last6=Romano |first6=G. |last7=Sicurezza |first7=E. |last8=Fiore |first8=C. E. |title=Doppler ultrasound and renal artery stenosis: An overview |journal=Journal of Ultrasound |date=1 December 2009 |volume=12 |issue=4 |pages=133–143 |doi=10.1016/j.jus.2009.09.006 |pmid=23397022 |pmc=3567456 |language=en |issn=1971-3495}}</ref>
The specific criteria for renal artery stenosis on Doppler are an acceleration time of greater than 70 milliseconds, an acceleration index of less than 300 cm/sec² and a velocity ratio of the renal artery to aorta of greater than 3.5.<ref name="Granata Fiorini Andrulli et al 2009"/>


==Treatment==
==Treatment==
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===Atherosclerotic renal artery stenosis===
===Atherosclerotic renal artery stenosis===
It is initially treated with medications, including [[diuretic]]s, and [[Antihypertensive drug|medications for blood pressure control]].<ref name=Renal2015/> When high-grade renal artery stenosis is documented and blood pressure cannot be controlled with medication, or if renal function deteriorates, [[surgery]] may be resorted to. The most commonly used procedure is a [[minimally-invasive procedures|minimally-invasive]] [[angioplasty]] with or without [[stent]]ing. It is unclear if this approach yields better results than the use of medications alone.<ref name=Cochrane2014>{{cite journal|last1=Jenks|first1=S|last2=Yeoh|first2=SE|last3=Conway|first3=BR|title=Balloon angioplasty, with and without stenting, versus medical therapy for hypertensive patients with renal artery stenosis.|journal=The Cochrane Database of Systematic Reviews|date=5 December 2014|volume=12|issue=12|pages=CD002944|pmid=25478936|doi=10.1002/14651858.CD002944.pub2}}</ref> It is a relatively safe procedure.<ref name=Cochrane2014/> If all else fails and the kidney is thought to be worsening hypertension and revascularization with angioplasty or surgery does not work, then surgical removal of the affected kidney ([[nephrectomy]]) may significantly improve high blood pressure.<ref>{{Cite book|title = Pediatric Solid Organ Transplantation|url = https://books.google.com/?id=NmHE1XsZ6ScC&pg=PA155&dq=nephrectomy)++may+reduce+hypertension#v=onepage&q=nephrectomy)%2520%2520may%2520reduce%2520hypertension&f=false|publisher = John Wiley & Sons|date = 2009-04-08|isbn = 9781444312737|first = Richard N.|last = Fine|first2 = Steven A.|last2 = Webber|first3 = William E.|last3 = Harmon|first4 = Deirdre|last4 = Kelly|first5 = Kim M.|last5 = Olthoff}}</ref>
It is initially treated with medications, including [[diuretic]]s, and [[Antihypertensive drug|medications for blood pressure control]].<ref name=Renal2015/> When high-grade renal artery stenosis is documented and blood pressure cannot be controlled with medication, or if renal function deteriorates, [[surgery]] may be resorted to. The most commonly used procedure is a [[minimally-invasive procedures|minimally-invasive]] [[angioplasty]] with or without [[stent]]ing. It is unclear if this approach yields better results than the use of medications alone.<ref name=Cochrane2014>{{cite journal |last1=Jenks |first1=Sara |last2=Yeoh |first2=Su Ern |last3=Conway |first3=Bryan R |title=Balloon angioplasty, with and without stenting, versus medical therapy for hypertensive patients with renal artery stenosis |journal=Cochrane Database of Systematic Reviews |date=5 December 2014 |volume=2014 |issue=12 |pages=CD002944 |doi=10.1002/14651858.CD002944.pub2 |pmid=25478936 |pmc=7138037 }}</ref> It is a relatively safe procedure.<ref name=Cochrane2014/> If all else fails and the kidney is thought to be worsening hypertension and revascularization with angioplasty or surgery does not work, then surgical removal of the affected kidney ([[nephrectomy]]) may significantly improve high blood pressure.<ref>{{Cite book|title = Pediatric Solid Organ Transplantation|url = https://books.google.com/books?id=NmHE1XsZ6ScC&q=nephrectomy%29%2520%2520may%2520reduce%2520hypertension&pg=PA155|publisher = John Wiley & Sons|date = 8 April 2009|isbn = 9781444312737|first1 = Richard N.|last1 = Fine|first2 = Steven A.|last2 = Webber|first3 = William E.|last3 = Harmon|first4 = Deirdre|last4 = Kelly|first5 = Kim M.|last5 = Olthoff|access-date = 28 October 2020|archive-date = 4 September 2024|archive-url = https://web.archive.org/web/20240904222701/https://books.google.com/books?id=NmHE1XsZ6ScC&q=nephrectomy%29%2520%2520may%2520reduce%2520hypertension&pg=PA155#v=snippet&q=nephrectomy)%2520%2520may%2520reduce%2520hypertension&f=false|url-status = live}}</ref>


===Fibromuscular dysplasia===
===Fibromuscular dysplasia===
Angioplasty with or without stenting is the best option for the treatment of renal artery stenosis due to [[fibromuscular dysplasia]].<ref>{{Cite journal|title = Treatment of hypertension in patients with renal artery stenosis due to fibromuscular dysplasia of the renal arteries - Chrysant - Cardiovascular Diagnosis and Therapy|issue = 1|pages = 36–43|journal = Cardiovascular Diagnosis and Therapy|volume = 4|date = 2014-02-21|last1 = Chrysant|first1 = Steven G.|last2 = Chrysant|first2 = George S.|pmid = 24649423|pmc = 3943779|doi = 10.3978/j.issn.2223-3652.2014.02.01}}</ref>
Angioplasty alone is preferred in [[fibromuscular dysplasia]], with stenting reserved for unsuccessful angioplasty or complications such as [[dissection]].<ref>{{cite journal |last1=Chrysant |first1=Steven G. |last2=Chrysant |first2=George S. |title=Treatment of hypertension in patients with renal artery stenosis due to fibromuscular dysplasia of the renal arteries |journal=Cardiovascular Diagnosis and Therapy |date=February 2014 |volume=4 |issue=1 |pages=36–43 |doi=10.3978/j.issn.2223-3652.2014.02.01 |pmid=24649423 |pmc=3943779 }}</ref>

==See also==
* [[Renovascular hypertension]]


==References==
==References==
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==Further reading==
==Further reading==
*{{Cite book|title = Renal and Electrolyte Disorders|url = https://books.google.com/?id=3IIqPtg-upwC&pg=PA304&dq=renal+artery+stenosis#v=onepage&q=renal%2520artery%2520stenosis&f=false|publisher = Lippincott Williams & Wilkins|date = 2010-01-01|isbn = 9781608310722|first = Robert W.|last = Schrier}}
* {{Cite book|title = Renal and Electrolyte Disorders|url = https://books.google.com/books?id=3IIqPtg-upwC&q=renal%2520artery%2520stenosis&pg=PA304|publisher = Lippincott Williams & Wilkins|date = 1 January 2010|isbn = 9781608310722|first = Robert W.|last = Schrier}}
* {{cite journal | vauthors = Trinquart L, Mounier-Vehier C, Sapoval M, Gagnon N, Plouin PF | display-authors = 3 | title=Efficacy of Revascularization For Renal Artery Stenosis Caused by Fibromuscular Dysplasia | journal=Hypertension | volume=56 | issue=3 | year=2010 | issn=0194-911X | pmid=20625080 | doi=10.1161/hypertensionaha.110.152918 | pages=525–532 | lay-url = http://www.crd.york.ac.uk/crdweb/ShowRecord.asp?LinkFrom=OAI&ID=12010006620 | doi-access=free }}
* {{cite journal | vauthors = Vasbinder GB, Nelemans PJ, Kessels AG, Kroon AA, de Leeuw PW, van Engelshoven JM | display-authors = 3 | title=Diagnostic Tests for Renal Artery Stenosis in Patients Suspected of Having Renovascular Hypertension | journal=Annals of Internal Medicine | volume=135 | issue=6 | pages = 401–11 | date=18 September 2001 | issn=0003-4819 | pmid=11560453 | doi=10.7326/0003-4819-135-6-200109180-00009 | lay-url = http://www.crd.york.ac.uk/crdweb/ShowRecord.asp?LinkFrom=OAI&ID=12001008384 }}


==External links==
==External links==
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{{Nephrology}}
{{Nephrology}}
{{Portal bar | Medicine}}
{{Authority control}}


[[Category:Articles containing video clips]]
[[Category:Articles containing video clips]]

Latest revision as of 01:59, 5 September 2024

Renal artery stenosis
SpecialtyNephrology
Risk factorsSmoking, High blood pressure[1]
Diagnostic methodCaptopril challenge test, Doppler ultrasound[2][3]
TreatmentACE inhibitors[1]

Renal artery stenosis (RAS) is the narrowing of one or both of the renal arteries, most often caused by atherosclerosis or fibromuscular dysplasia. This narrowing of the renal artery can impede blood flow to the target kidney, resulting in renovascular hypertension – a secondary type of high blood pressure. Possible complications of renal artery stenosis are chronic kidney disease and coronary artery disease.[1]

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.[4] Decreased kidney function may develop if both kidneys do not receive adequate blood flow, furthermore some people with renal artery stenosis present with episodes of flash pulmonary edema.[5]

Cause

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Renal artery stenosis is most often caused by atherosclerosis which causes the renal arteries to harden and narrow due to the build-up of plaque. This is known as atherosclerotic renovascular disease, which accounts for about 90% of cases.[6] This narrowing of renal arteries due to plaque build-up leads to higher blood pressure within the artery and decreased blood flow to the kidney. This decreased blood flow leads to decreased blood pressure in the kidney, which leads to the activation of the Renin-Angiotensin-Aldosterone (RAA) system. Juxtaglomerular cells secrete renin, which converts angiotensinogen to angiotensin I, which is then converted to angiotensin II by angiotensin converting enzyme (ACE). Angiotensin II then acts on the adrenal cortex to increase secretion of the hormone aldosterone. Aldosterone causes sodium and water retention, leading to an increase in blood volume and blood pressure. Therefore, people with RAS have chronic high blood pressure because their RAA system is hyperactivated.[7]

Pathophysiology

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The pathophysiology of renal artery stenosis leads to changes in the structure of the kidney that are most noticeable in the tubular tissue.[8]

Changes include:[8]

Diagnosis

[edit]
Assessment of Kidneys with Renal Artery Stenosis taken by Magnetic Resonance Angiography.

The diagnosis of renal artery stenosis can use many techniques to determine if the condition is present, a clinical prediction rule is available to guide diagnosis.[9]

Among the diagnostic techniques are:

The specific criteria for renal artery stenosis on Doppler are an acceleration time of greater than 70 milliseconds, an acceleration index of less than 300 cm/sec² and a velocity ratio of the renal artery to aorta of greater than 3.5.[2]

Treatment

[edit]
A diuretic (Hydrochlorothiazide)

Atherosclerotic renal artery stenosis

[edit]

It is initially treated with medications, including diuretics, and medications for blood pressure control.[8] When high-grade renal artery stenosis is documented and blood pressure cannot be controlled with medication, or if renal function deteriorates, surgery may be resorted to. The most commonly used procedure is a minimally-invasive angioplasty with or without stenting. It is unclear if this approach yields better results than the use of medications alone.[15] It is a relatively safe procedure.[15] If all else fails and the kidney is thought to be worsening hypertension and revascularization with angioplasty or surgery does not work, then surgical removal of the affected kidney (nephrectomy) may significantly improve high blood pressure.[16]

Fibromuscular dysplasia

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Angioplasty alone is preferred in fibromuscular dysplasia, with stenting reserved for unsuccessful angioplasty or complications such as dissection.[17]

References

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  1. ^ a b c "Renal Artery Stenosis". National Institute of Diabetes and Digestive and Kidney Diseases. Archived from the original on 16 December 2016. Retrieved 17 August 2015.
  2. ^ a b c Granata A, Fiorini F, Andrulli S, Logias F, Gallieni M, Romano G, et al. (December 2009). "Doppler ultrasound and renal artery stenosis: An overview". Journal of Ultrasound. 12 (4): 133–143. doi:10.1016/j.jus.2009.09.006. PMC 3567456. PMID 23397022.
  3. ^ a b Ong YY (1 January 2005). A Clinical Approach to Medicine. World Scientific. ISBN 9789812560735. Archived from the original on 4 September 2024. Retrieved 28 October 2020.
  4. ^ MedlinePlus Encyclopedia: Renovascular hypertension
  5. ^ Messerli FH, Bangalore S, Makani H, Rimoldi SF, Allemann Y, White CJ, et al. (2 September 2011). "Flash pulmonary oedema and bilateral renal artery stenosis: the Pickering Syndrome". European Heart Journal. 32 (18): 2231–2235. doi:10.1093/eurheartj/ehr056. PMID 21406441.
  6. ^ Vassallo D, Kalra PA (2017). "Atherosclerotic renovascular disease – epidemiology, treatment and current challenges". Advances in Interventional Cardiology. 3 (3): 191–201. doi:10.5114/aic.2017.70186. PMC 5644037. PMID 29056991.
  7. ^ Safian RD (March 2021). "Renal artery stenosis". Progress in Cardiovascular Diseases. 65: 60–70. doi:10.1016/j.pcad.2021.03.003. PMID 33745915. S2CID 232311595.
  8. ^ a b c Renal Artery Stenosis at eMedicine
  9. ^ Steyerberg E (16 December 2008). Clinical Prediction Models: A Practical Approach to Development, Validation, and Updating. Springer Science & Business Media. ISBN 9780387772448. Archived from the original on 4 September 2024. Retrieved 28 October 2020.
  10. ^ Protasiewicz M, Kądziela J, Początek K, Poręba R, Podgórski M, Derkacz A, et al. (November 2013). "Renal Artery Stenosis in Patients With Resistant Hypertension". The American Journal of Cardiology. 112 (9): 1417–1420. doi:10.1016/j.amjcard.2013.06.030. PMID 24135303.
  11. ^ Talley NJ, O'Connor S (20 September 2013). Clinical Examination: A Systematic Guide to Physical Diagnosis. Elsevier Health Sciences. ISBN 9780729541473. Archived from the original on 4 September 2024. Retrieved 28 October 2020.
  12. ^ Taylor AT (May 2014). "Radionuclides in Nephrourology, Part 2: Pitfalls and Diagnostic Applications". Journal of Nuclear Medicine. 55 (5): 786–798. doi:10.2967/jnumed.113.133454. PMC 4451959. PMID 24591488.
  13. ^ Sam AH, James T.H. Teo (2010). Rapid Medicine. Wiley-Blackwell. ISBN 978-1405183239.
  14. ^ Attenberger UI, Morelli JN, Schoenberg SO, Michaely HJ (December 2011). "Assessment of the kidneys: magnetic resonance angiography, perfusion and diffusion". Journal of Cardiovascular Magnetic Resonance. 13 (1): 70. doi:10.1186/1532-429X-13-70. PMC 3228749. PMID 22085467.
  15. ^ a b Jenks S, Yeoh SE, Conway BR (5 December 2014). "Balloon angioplasty, with and without stenting, versus medical therapy for hypertensive patients with renal artery stenosis". Cochrane Database of Systematic Reviews. 2014 (12): CD002944. doi:10.1002/14651858.CD002944.pub2. PMC 7138037. PMID 25478936.
  16. ^ Fine RN, Webber SA, Harmon WE, Kelly D, Olthoff KM (8 April 2009). Pediatric Solid Organ Transplantation. John Wiley & Sons. ISBN 9781444312737. Archived from the original on 4 September 2024. Retrieved 28 October 2020.
  17. ^ Chrysant SG, Chrysant GS (February 2014). "Treatment of hypertension in patients with renal artery stenosis due to fibromuscular dysplasia of the renal arteries". Cardiovascular Diagnosis and Therapy. 4 (1): 36–43. doi:10.3978/j.issn.2223-3652.2014.02.01. PMC 3943779. PMID 24649423.

Further reading

[edit]
[edit]
Scholia has a topic profile for Renal artery stenosis.
Retrieved from "https://en.wikipedia.org/enwiki/w/index.php?title=Renal_artery_stenosis&oldid=1244104643"