From the Guidelines
Renal artery stenosis often presents with symptoms related to reduced kidney function and hypertension, including difficult-to-control high blood pressure, declining kidney function, and flash pulmonary edema, as noted in a 2018 study by the American Heart Association 1. The most common symptoms of renal artery stenosis include:
- Difficult-to-control high blood pressure (resistant hypertension), especially in patients who previously had well-controlled blood pressure or who develop hypertension before age 30 or after age 55
- Declining kidney function with elevated creatinine levels, particularly after starting ACE inhibitors or ARBs
- Flash pulmonary edema (sudden fluid buildup in the lungs) or recurrent heart failure
- Headaches, dizziness, and swelling in the extremities
- An audible bruit (whooshing sound) over the abdomen or flank when listening with a stethoscope These symptoms occur because narrowing of the renal artery reduces blood flow to the kidney, triggering the renin-angiotensin-aldosterone system, which raises blood pressure and causes fluid retention, as discussed in the 2018 study 1. Many cases of renal artery stenosis remain asymptomatic until advanced stages, making it essential to consider this diagnosis in patients with unexplained hypertension or worsening kidney function, especially those with risk factors like atherosclerosis, smoking, or fibromuscular dysplasia, as highlighted in the study 1.
From the Research
Symptoms of Renal Artery Stenosis
The symptoms of renal artery stenosis (RAS) can be varied and are often associated with three major clinical syndromes:
- Ischemic nephropathy
- Hypertension
- Destabilizing cardiac syndromes 2 Some common symptoms and associated conditions include:
- Refractory hypertension
- Progressive renal insufficiency
- Cardiovascular complications such as refractory heart failure and flash pulmonary edema 3
- Uncontrolled renovascular hypertension despite optimal medical therapy 3
- Ischemic nephropathy and cardiac destabilization syndromes 3
Diagnosis and Treatment
Diagnosis of RAS can be done with non-invasive methods such as Doppler ultrasonography, CT angiography, and magnetic resonance angiography 3. Treatment approaches include medical therapy, such as risk factor modification, renin-angiotensin-aldosterone system antagonists, lipid-lowering agents, and antiplatelet therapy 3, as well as renal artery revascularization in selected patients 4, 3. In patients with bilateral renal artery stenosis, angiotensin-converting enzyme inhibitors (ACEIs) are contraindicated due to the risk of azotemia, but may be safely used after successful revascularization using renal artery stenting 5.
Clinical Considerations
When evaluating patients for RAS, consider renovascular hypertension when newly diagnosed hypertension presents with atypical features, resistant hypertension is associated with risk factors for atheroma, or ACE inhibitor or angiotensin-II-receptor antagonist therapy is associated with increasing plasma creatinine levels 6. Atheromatous renovascular hypertension can often be managed medically, including intensive correction of cardiovascular risk factors 6.