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Renal artery stenosis

Key sources
The following summarized guidelines for the evaluation and management of renal artery stenosis are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2021), the Japanese Society of Nephrology (JSN 2019), the European Society of Cardiology (ESC/ESVS 2018), the Canadian Hypertension Education Program (CHEP 2018), and the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA 2018).


1.Screening and diagnosis

Indications for screening: as per AHA 2018 guidelines, screen for renovascular hypertension using renal Doppler ultrasound, MRA, or abdominal CT in the presence of the following clinical indications and physical examination findings:
resistant hypertension, hypertension of abrupt onset or worsening or increasingly difficult to control, flash pulmonary edema (atherosclerotic), early-onset hypertension, especially in women (fibromuscular hyperplasia)
abdominal systolic-diastolic bruit, bruits over carotid (atherosclerotic or FMD) or femoral arteries.
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2.Diagnostic investigations

Renal artery imaging
Obtain duplex ultrasound as first-line imaging modality, or CTA (when eGFR is ≥ 60 mL/min) or MRA (when eGFR is ≥ 30 mL/min), to establish a diagnosis of renal artery disease.
Do not obtain renal scintigraphy for the evaluation of atherosclerotic renal artery disease.

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3.Diagnostic procedures

Catheter-based contrast angiography: consider obtaining digital subtraction angiography to confirm a diagnosis of renal artery disease when clinical suspicion is high and the results of noninvasive examinations are inconclusive.

4.Medical management

Antihypertensive therapy: as per JSN 2019 guidelines, consider initiating RAAS inhibitors in patients with CKD with unilateral renal artery stenosis because it is superior in reducing BP in such patients compared to other antihypertensive drugs and may reduce progression to mortality, the onset of CVD, and progression of renal dysfunction. Adjust the dose carefully starting with a low dose and assessing the serum creatinine and potassium levels approximately 2 weeks after initiation to avoid the risk of AKI. Do not use a renin-angiotensin system inhibitor when bilateral renal artery stenosis is suspected.

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5.Nonpharmacologic interventions

Lifestyle modifications: advise smoking cessation
, healthy diet and physical activity in all patients with PADs.

6.Therapeutic procedures

Indications for revascularization: as per JSN 2019 guidelines, avoid performing revascularization in patients with CKD with arteriosclerotic renal artery stenosis due to the risk of complications because it does not suppress the progression of renal dysfunction or decrease the risk of developing CVD.

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7.Surgical interventions

Surgical revascularization: as per CHEP 2018 guidelines, consider performing surgical revascularization in patients with complex lesions less amendable to angioplasty, stenosis associated with complex aneurysm, and restenosis despite two unsuccessful attempts of angioplasty.

8.Specific circumstances

Patients with transplant renal artery stenosis: suspect transplant renal artery stenosis in case of refractory arterial hypertension and/or increasing serum creatinine without hydronephrosis/infection.
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9.Quality improvement

Hospital requirements: healthcare centers should set up a multidisciplinary vascular team to make decisions for the management of patients with PADs.