From the Guidelines
The primary recommendation for managing renal artery stenosis (RAS) is medical therapy, particularly with ACE inhibitors or ARBs, as stated in the 2017 ESC guidelines 1. This approach is based on the strongest and most recent evidence, which suggests that medical management is effective in treating hypertension and slowing the progression of renal disease in patients with RAS.
Key Recommendations
- Medical therapy is the first line of treatment, with ACEIs/ARBs recommended for treatment of hypertension associated with unilateral RAS 1.
- Calcium channel blockers, beta-blockers, and diuretics are also recommended for treatment of hypertension associated with renal artery disease 1.
- Revascularization is not routinely recommended in RAS secondary to atherosclerosis, but may be considered in selected patients with specific indications, such as hypertension and/or signs of renal impairment related to renal arterial fibromuscular dysplasia 1.
Medical Therapy
- ACEIs/ARBs, such as lisinopril or losartan, are effective in reducing mortality and morbidity in patients with RAS, but require careful monitoring, especially in patients with bilateral severe RAS or a single functioning kidney 1.
- Statins, such as atorvastatin, are associated with improved survival, slower lesion progression, and reduced restenosis risk after renal stenting 1.
- Antiplatelet therapy, such as aspirin, should be part of the medical management 1.
Lifestyle Modifications
- Smoking cessation, regular exercise, weight management, and sodium restriction are essential components of management, as they can help control blood pressure and slow the progression of renal disease. By prioritizing medical therapy and lifestyle modifications, patients with RAS can achieve optimal blood pressure control and reduce the risk of morbidity and mortality, while minimizing the risks associated with revascularization procedures.
From the Research
Recommendations for Managing Renal Artery Stenosis (RAS)
- Medical management is preferred over angioplasty and stenting for the treatment of RAS, as emphasized by major clinical trials 2, 3.
- However, percutaneous interventions, such as angioplasty and stent insertion, may be beneficial in certain clinical scenarios, including refractory severe hypertension and ischemic nephropathy 2, 4.
- Patients with atherosclerotic RAS and hypertension should be treated aggressively with antihypertensive medical therapy, and renal artery revascularization with stenting may be considered for those with refractory severe hypertension or end-organ injury 4, 3.
- The best candidates for revascularization are those with baseline serum creatinine less than 2.0 mg/dL, bilateral renal artery stenosis, normal renal resistive indices, no proteinuria, and one or more manifestations of end-organ injury 4.
- Medical therapy, including angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACE-is), may exert beneficial effects in patients with RAS, and can be used in conjunction with revascularization procedures 5, 6.
- Optimal medical therapy should include the use of medicines to control blood pressure, as well as agents proven to reduce cardiovascular morbidity and mortality, such as anti-platelet drugs and statins 3.