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Renal artery stenosis
Background
Overview
Definition
Renal artery stenosis is the narrowing of one or both renal arteries, leading to decreased blood flow to the kidneys.
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Pathophysiology
The most common causes of renal artery stenosis are atherosclerosis and FMD, accounting for approximately 90% and 10% of renal artery stenosis cases, respectively. Renal artery stenosis decreases renal perfusion, triggering the RAAS, which leads to renovascular hypertension and may cause ischemic nephropathy, resulting in progressive renal dysfunction.
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Epidemiology
The prevalence of renal artery stenosis in the general population is estimated at 5-10%, and as high as 25% in elderly patients with hypertension.
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Risk factors
Risk factors for renal atherosclerosis include older age, diabetes mellitus, dyslipidemia, tobacco use, PAD, and a family history of CVD. Risk factors for FMD include female sex, tobacco use, and a family history of FMD.
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Disease course
Clinically, renal artery stenosis can present with refractory hypertension, impaired renal function, pulmonary edema, and congestive HF. Physical examination may reveal an abdominal bruit.
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Prognosis and risk of recurrence
The prognosis of renal artery stenosis can be severe if left untreated, potentially leading to CKD or ESRD. Patients undergoing revascularization for hypertension related to atherosclerotic stenosis should continue pharmacotherapy after the procedure to prevent renal and cardiovascular events. Restenosis occurs in 10-25% of cases.
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Guidelines
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 2025), the European Society of Cardiology (ESC 2024), the Japanese Society of Nephrology (JSN 2019), the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA 2018), the Canadian Hypertension Education Program (CHEP 2018), and ...
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Screening and diagnosis
Indications for screening: as per AAPA/ABC/ACC/…/PCNA 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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Diagnostic investigations
Medical management
Antihypertensive therapy: as per ESC 2024 guidelines, initiate antihypertensive therapy with ACEis/ARBs in patients with unilateral renal artery stenosis.
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Aspirin
Management of dyslipidemia
Glycemic control
Nonpharmacologic interventions
Smoking cessation: as per ESC 2024 guidelines, advise cessation and abstinence from smoking of any kind in patients with aortic disease to reduce the risk of myocardial infarction and death.
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Dietary changes
Therapeutic procedures
Indications for revascularization: as per ESC 2024 guidelines, consider performing renal artery revascularization in patients with atherosclerotic unilateral ≥ 70% renal artery stenosis, concomitant high-risk features, and signs of kidney viability after optimal medical therapy has been established.
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Renal artery angioplasty