Can renal denervation be performed in patients with revascularized renal (kidney) stenosis?

Renal Denervation in Revascularized Renal Stenosis

Renal denervation should not be performed in patients with revascularized renal artery stenosis due to the risk of worsening renal function and potential complications. 1

Rationale Against Renal Denervation in Revascularized Renal Stenosis

The current guidelines from major cardiovascular societies do not support renal denervation in patients with renal artery stenosis, including those who have undergone revascularization procedures. There are several important reasons for this:

1. Risk of restenosis: There have been reported cases of renal artery stenosis developing after renal denervation procedures, even in patients without pre-existing stenosis 2, 3. This risk could be higher in patients with a history of renal artery stenosis who have undergone revascularization.

2. Lack of evidence: Current clinical trials on renal denervation have typically excluded patients with renal artery stenosis or previous revascularization procedures 4, 5.

3. Alternative management approaches: For patients with revascularized renal stenosis, the focus should be on optimizing medical therapy rather than additional interventional procedures 6.

Management Approach for Patients with Revascularized Renal Stenosis

Medical Management

• Optimize antihypertensive therapy with a three-drug combination (ACE inhibitor/ARB, calcium channel blocker, and thiazide-like diuretic) 1
• RAAS blockers (ACE inhibitors or ARBs) should be introduced in all patients with atherosclerotic renovascular disease (ARVD) 6
• Careful monitoring is required when using RAAS blockers in patients with bilateral renal artery stenosis or stenosis in a solitary functioning kidney 6
• Statins are associated with improved survival, slower lesion progression, and reduced restenosis risk after renal stenting 6
• Antiplatelet therapy should be part of best medical therapy 6

Monitoring and Follow-up

• Regular monitoring of renal function is essential, especially when using ACE inhibitors or ARBs 1
• After renal artery stenting, follow-up is recommended at 1 month and subsequently every 12 months or when new signs or symptoms arise 6
• Re-intervention may be considered for in-stent restenosis ≥60% detected by duplex ultrasound, recurrent signs and symptoms (diastolic BP >90 mmHg on >3 antihypertensive drugs, or a >20% increase in serum creatinine) 6
• Duplex ultrasound is recommended as the first-line imaging modality for follow-up 6, 7

When to Consider Revascularization (Not Denervation)

In specific cases, repeat revascularization (not denervation) may be considered:

• Flash pulmonary edema or acute decompensations of heart failure 6
• Progressive CKD in high-grade renal artery stenosis if bilateral or affecting a solitary kidney 6
• Resistant hypertension with viable kidney parenchyma 6
• Acute kidney injury due to acute renal artery occlusion or high-grade stenosis 6
• Intolerance of ACE inhibitors or ARBs in high-grade renal artery stenosis when such therapy is necessary 6

Assessment of Kidney Viability

Before considering any intervention, assessment of kidney viability is crucial 6:

• Viable kidney indicators: Renal length >8 cm, distinct cortex (>0.5 cm), albumin-creatinine ratio <200 mg/g, renal resistive index <0.8
• Non-viable kidney indicators: Renal length <7 cm, loss of corticomedullary differentiation, albumin-creatinine ratio >300 mg/g, renal resistive index >0.8

Conclusion

The evidence strongly suggests avoiding renal denervation in patients with revascularized renal stenosis. Instead, focus should be on optimizing medical therapy, careful monitoring, and considering repeat revascularization only in specific high-risk scenarios with evidence of kidney viability.