From the Guidelines
Starting ACE inhibitors in a patient with bilateral renal artery stenosis should be done with caution and close monitoring, as these medications can reduce glomerular capillary hydrostatic pressure and cause a transient decrease in glomerular filtration rate, although they may be introduced in carefully selected patients. According to the 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases 1, most patients with significant renal artery stenosis (RAS) tolerate ACE inhibitors or angiotensin II receptor blockers (ARBs) without difficulty, and these drugs have shown benefits in reducing mortality and morbidity in patients with renal artery disease. However, the guidelines also emphasize the importance of careful monitoring, as ACE inhibitors and ARBs can cause a transient decrease in glomerular filtration rate and raise serum creatinine.
Key considerations when starting ACE inhibitors in patients with bilateral renal artery stenosis include:
- Close monitoring of kidney function, especially within the first 1-2 weeks of treatment
- Careful selection of patients, taking into account the severity of the stenosis and the presence of other comorbidities
- Alternative antihypertensive medications, such as calcium channel blockers or beta-blockers, may be considered instead
- The potential benefits of ACE inhibitors in reducing mortality and morbidity in patients with renal artery disease should be weighed against the potential risks of acute kidney injury and worsening blood pressure control.
It is worth noting that the 2011 ESC guidelines on the diagnosis and treatment of peripheral artery diseases 1 recommend that ACE inhibitors and ARBs are contraindicated in bilateral severe RAS and in the case of RAS in a single functional kidney, highlighting the importance of careful patient selection and monitoring. However, the more recent 2017 guidelines 1 suggest that ACE inhibitors may be introduced in carefully selected patients with bilateral RAS, provided that they are closely monitored.
From the Research
Effects of ACE Inhibitors on Bilateral Renal Artery Stenosis
- Starting ACE inhibitors in a patient with bilateral renal artery stenosis can lead to a risk of azotemia due to preferential efferent arteriolar vasodilation in the renal glomerulus resulting from inhibition of angiotensin II 2, 3.
- ACE inhibitors are generally contraindicated in patients with bilateral renal artery stenosis due to the risk of deterioration of renal function 3, 4.
- However, patients with bilateral renal artery stenosis who have undergone successful revascularization using renal artery stenting may be safely treated with long-term ACEI therapy 2.
- The use of ACE inhibitors in patients with renal artery stenosis remains controversial, and treatment should be individualized based on the patient's specific condition and clinical indications 3, 4.
Renal Function and ACE Inhibitors
- ACE inhibitors can cause a decline in glomerular filtration rate (GFR) in the kidney affected by the stenosis, whether or not clinically apparent renal insufficiency occurs 3.
- The effects of ACE inhibitors on renal hemodynamics vary widely depending on the preexisting physiologic and pathologic state of the kidneys 3.
- In patients with decompensated cardiac failure, renal perfusion pressures may already be at or near the autoregulatory breakpoint, and ACE inhibition may cause deterioration of renal function 3.
Treatment Options for Bilateral Renal Artery Stenosis
- Revascularization is recommended if patients have at least 75% stenosis of one or both renal arteries, combined with resistant or poorly controlled hypertension, recurrent flash pulmonary edema, or chronic renal insufficiency 4.
- Percutaneous transluminal angioplasty and stent implantation is the revascularization procedure of choice for treating atherosclerotic renal artery stenosis 4.
- Bilateral renal artery stenting can provide beneficial outcomes, such as stabilization of renal functions, significant improvement in blood pressure control, and reduction in the number of oral antihypertensive medications 5.