What is the relationship between renal disease and renovascular hypertension?

From the Guidelines

Renal disease and renovascular hypertension have a complex bidirectional relationship, where each condition can influence the development and progression of the other, and management typically involves addressing both conditions simultaneously with antihypertensive medications and possible revascularization procedures. Renovascular hypertension occurs when narrowing of the renal arteries (renal artery stenosis) reduces blood flow to the kidneys, triggering the renin-angiotensin-aldosterone system (RAAS) and causing elevated blood pressure, as stated in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. This condition can lead to secondary kidney damage over time. Conversely, primary kidney diseases like diabetic nephropathy, glomerulonephritis, or polycystic kidney disease can cause hypertension through fluid retention, RAAS activation, and endothelial dysfunction.

Management of Renovascular Hypertension

The management of renovascular hypertension involves a combination of medical therapy and possible revascularization procedures. According to the 2024 ESC guidelines, renal artery angioplasty without stenting should be considered for patients with hypertension and haemodynamically significant renal artery stenosis due to fibromuscular dysplasia 1. For patients with atherosclerotic renal artery stenosis, renal artery angioplasty and stenting may be considered in certain cases, such as recurrent heart failure, unstable angina, or sudden-onset flash pulmonary oedema despite maximally tolerated medical therapy.

Medical Therapy

Medical therapy for renovascular hypertension typically involves the use of antihypertensive medications, particularly ACE inhibitors or ARBs, which block the RAAS pathway. However, these medications must be used cautiously in bilateral renal artery stenosis as they may worsen kidney function, as noted in the 2024 ESC guidelines 1. Other treatments include diuretics like hydrochlorothiazide to reduce fluid retention, and calcium channel blockers such as amlodipine.

Monitoring and Follow-up

Regular monitoring of blood pressure, kidney function (creatinine, eGFR), and electrolytes is essential, with target blood pressure typically below 130/80 mmHg for patients with kidney disease. This is crucial in managing both the renal disease and renovascular hypertension, and in preventing further progression of these conditions. By addressing both conditions simultaneously and closely monitoring the patient's response to treatment, healthcare providers can help to improve outcomes and reduce the risk of morbidity and mortality associated with these conditions.

From the FDA Drug Label

In patients with renovascular hypertension lisinopril has been shown to be well tolerated and effective in reducing blood pressure [see Warnings and Precautions (5. 3)]. The relationship between renal disease and renovascular hypertension is that lisinopril is effective in reducing blood pressure in patients with renovascular hypertension.

• Lisinopril is well-tolerated in these patients.
• The drug label does not provide further details on the relationship between renal disease and renovascular hypertension beyond the efficacy of lisinopril in this patient population 2.

From the Research

Relationship Between Renal Disease and Renovascular Hypertension

The relationship between renal disease and renovascular hypertension is complex, with renal artery stenosis being a common cause of renovascular hypertension 3, 4, 5.

• Renovascular hypertension refers to the rise of arterial pressure due to reduced perfusion of the kidney caused by the stenotic renal artery/ies 3.
• Atherosclerotic renal stenosis is usually part of a systemic syndrome that involves hypertension, intrinsic renal damage, and cardiovascular morbidity 3.
• Renal artery stenosis can lead to progressive renal injury, cardiovascular complications, and 'flash pulmonary edema' 5.

Diagnostic and Therapeutic Approaches

Diagnostic work-up for hemodynamically significant renal artery stenosis should be restricted to patients suspected to be at moderate or high risk for renovascular disease 4.

• Patients at moderate risk should first undergo a screening test, like Doppler ultrasonography or captopril-enhanced scintigraphy 4.
• A renal artery stenosis with narrowing of > 50-60% of the lumen, is considered hemodynamically significant, and may be suitable for treatment with angioplasty or angioplasty plus stent placement (in case of osteal renal artery stenosis) 4.
• Therapeutic options available include medical therapy, percutaneous angioplasty with or without stent placement, and surgical revascularization 5.

Management and Treatment

Optimal medical therapy with antihypertensive, lipid-lowering, and platelet-inhibiting drugs should be instituted 3, 4.

• Antihypertensive treatment should include renin-angiotensin system blockade medication in most cases, while HMG-CoA reductase inhibitors (statins) can be used even in chronic kidney disease with safety 3.
• First line antihypertensive drugs for treating patients with kidney disease are ACE-Inhibitors or Angiotensin receptor blockers in combination with diuretics and a low sodium diet 6.
• Revascularization is only recommended for patients with progressive worsening of renal function, recurrent 'flash pulmonary edema' and rapid increase in antihypertensive requirement in patients with previously well-controlled hypertension 5.