From the Guidelines
The management of a kidney with a duplicated renal moiety and impaired perfusion should prioritize revascularization with primary balloon angioplasty and bailout stenting, especially in cases with hypertension and/or signs of renal dysfunction due to renal artery stenosis caused by fibromuscular dysplasia, as recommended by the 2024 ESC guidelines 1.
Initial Assessment and Treatment
The initial approach involves a comprehensive assessment of the patient's condition, including the extent of renal impairment and the underlying cause of poor perfusion. Optimizing blood pressure with medications such as ACE inhibitors or ARBs is crucial to maintain adequate renal perfusion without causing hypotension, as suggested by general medical principles. Ensuring adequate hydration while avoiding volume overload is also vital, typically through careful fluid management targeting euvolemia.
Revascularization Considerations
Revascularization should be considered in patients with atherosclerotic unilateral >70% renal artery stenosis (RAS), concomitant high-risk features, and signs of kidney viability, as per the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1. This approach is particularly relevant for patients with hypertension and/or signs of renal dysfunction due to RAS caused by fibromuscular dysplasia, where revascularization with primary balloon angioplasty and bailout stenting is recommended 1.
Monitoring and Follow-Up
Regular monitoring of renal function with serum creatinine, BUN, and estimated GFR every 1-3 months is essential to assess the effectiveness of the treatment and the progression of renal impairment. Imaging follow-up with renal ultrasound every 3-6 months helps evaluate changes in hydronephrosis or further deterioration, guiding the need for adjustments in the treatment plan.
Surgical Interventions
In cases where revascularization is not feasible or has failed, open surgical revascularization should be considered, especially in patients with complex anatomy or after failed endovascular revascularization, as suggested by the guidelines 1. For cases with significant obstruction causing the perfusion issues, drainage procedures such as ureteral stent placement or percutaneous nephrostomy may be necessary. In severe cases with irreversible damage to one moiety and preserved function in the other, partial nephrectomy of the poorly functioning segment might be considered to prevent recurrent infections and other complications.
From the Research
Management and Treatment
The management and treatment of a kidney with a duplicated renal moiety (double moiety) and impaired perfusion is not directly addressed in the provided studies. However, some studies discuss the management of related conditions, such as chronic kidney disease (CKD) and acute kidney injury (AKI).
Related Conditions
- CKD is a condition where the kidneys lose their function over time, and it can be associated with high mortality and morbidity 2.
- AKI is a sudden loss of kidney function, and it can be caused by various factors, including ischemia-reperfusion injury (IRI) 3.
- Impaired renal perfusion can be a consequence of AKI, and it can worsen renal outcome despite reduced glomerulosclerosis 3.
Treatment Strategies
- Antihypertensive treatment can be used to manage blood pressure in patients with CKD, but it may not always be effective in improving renal outcomes 3, 4.
- Renin-angiotensin-aldosterone axis inhibitor therapy can be beneficial in patients with mild-to-moderate CKD, but it may not be used in all suitable patients due to fear of hyperkalemia and worsening kidney function 2.
- Sodium-glucose cotransporter inhibitor therapy can improve mortality and hospitalization in patients with heart failure and CKD stages 3 and 4 2.
- A multidisciplinary approach, including combined cardiology-nephrology clinics, may be necessary for the implementation of evidence-based therapy in patients with CKD and heart failure 2.