From the Guidelines
Renal artery stenosis often presents with symptoms related to reduced kidney blood flow and resulting hypertension, including difficult-to-control high blood pressure, declining kidney function, and potential kidney damage if left untreated. Common symptoms include:
- Difficult-to-control high blood pressure, especially in patients who previously had well-controlled blood pressure or who suddenly develop hypertension before age 30 or after age 55 1
- Declining kidney function, particularly after starting ACE inhibitors or ARBs 1
- Physical examination may reveal an audible bruit over the affected renal artery
- In advanced cases, patients might develop fluid retention with swelling in the legs, shortness of breath, or decreased urine output
- Headaches, dizziness, and visual changes can occur due to severe hypertension
- Some patients may have no symptoms at all, with the condition discovered incidentally during imaging for other reasons 1
The symptoms result from the narrowing of one or both renal arteries, which triggers the renin-angiotensin-aldosterone system, leading to systemic hypertension and potential kidney damage if left untreated. According to the 2024 ESC guidelines, medical therapy is the first-line treatment for renovascular hypertension, and percutaneous transluminal renal angioplasty (PTRA) without stenting is the treatment of choice for fibromuscular dysplasia 1.
Key Considerations
- The narrowing of the renal arteries can lead to a wide spectrum of manifestations, ranging from incidental, asymptomatic findings to accelerated hypertension and renal insufficiency 1
- Moderate degrees of renovascular hypertension can often be managed with medical therapy, particularly with the use of agents that block the renin-angiotensin system (ACE inhibitors/ARBs) 1
- A subset of medically treated patients may develop progressive disease syndromes with worsening hypertension, renal insufficiency, or circulatory congestion, which carry high mortality risks 1
Diagnosis and Treatment
- Diagnosis of renal artery stenosis depends on clinical suspicion and consideration for arterial imaging for subjects with unexplained progressive hypertension or renal dysfunction 1
- Duplex imaging to identify increased peak systolic velocity in the renal arteries is most commonly used, often with confirmation by computed tomography angiography or magnetic resonance angiography before invasive studies 1
- Restoring main renal artery patency with endovascular stenting is also likely to reduce arterial BP, albeit with a residual requirement for antihypertensive drug therapy 1
From the Research
Symptoms of Renal Artery Stenosis
The symptoms of renal artery stenosis can be varied and may include:
- Hypertension (high blood pressure) 2, 3, 4, 5, 6
- Renal insufficiency (e.g., ischemic kidney disease) 2, 3, 6
- Pulmonary edema (fluid buildup in the lungs) 2, 3, 4, 5
- Refractory heart failure (heart failure that does not respond to treatment) 3, 4
- Flash pulmonary edema (sudden onset of pulmonary edema) 4, 5
- Congestive heart failure 3, 6
- Nephropathy (kidney disease) 6
- End-stage kidney failure 6
Clinical Presentation
Renal artery stenosis can be asymptomatic in some cases, but it can also present with a range of clinical symptoms, including:
- Resistant hypertension (high blood pressure that does not respond to treatment) 2, 3, 4, 5, 6
- Uncontrolled renovascular hypertension 2, 3, 4
- Progressive renal failure 2, 3, 4, 6
- Cardiovascular complications (e.g., heart failure, pulmonary edema) 2, 3, 4, 5
Diagnosis and Management
Renal artery stenosis can be diagnosed using various imaging modalities, including:
- Doppler ultrasonography 2, 3, 5, 6
- Computed tomography angiography (CTA) 2, 3, 5, 6
- Magnetic resonance angiography (MRA) 2, 3, 5, 6
- Renal angiography 5 Management of renal artery stenosis typically involves controlling blood pressure and addressing underlying risk factors, as well as considering revascularization procedures (e.g., angioplasty, stenting) in selected cases 2, 3, 4, 5, 6.