What is the role of renal angioplasty in patients with End-Stage Renal Disease (ESRD)?

From the Guidelines

Renal angioplasty is not recommended for patients with End-Stage Renal Disease (ESRD) unless they have confirmed haemodynamically significant renal artery stenosis, as it typically offers minimal benefit in this population. The European Heart Journal's 2024 guidelines for the management of elevated blood pressure and hypertension state that renal artery angioplasty is not recommended in patients without confirmed haemodynamically significant renal artery stenosis 1. This is because the procedure is most effective in patients with renal artery stenosis who have salvageable kidney function, which is not the case in ESRD.

Key Considerations

• The procedure may occasionally be considered in very specific circumstances, such as in patients with refractory hypertension despite multiple medications, recurrent flash pulmonary edema, or to preserve function in a remaining kidney.
• When performed, the procedure involves antiplatelet therapy with aspirin (81-325mg daily) before and after the procedure, and often clopidogrel (75mg daily) for 1-3 months post-stenting.
• Patients should be monitored for complications including contrast-induced nephropathy (though less concerning in ESRD patients already on dialysis), bleeding, arterial dissection, and restenosis.
• The limited utility of renal angioplasty in ESRD stems from the irreversible nature of the kidney damage at this stage, where the structural and functional changes cannot be meaningfully reversed by improving renal blood flow alone.

Evidence-Based Recommendations

• The 2024 ESC guidelines recommend that percutaneous transluminal renal angioplasty (PTRA) and stenting be performed in experienced centers due to the high risk of restenosis 1.
• The guidelines also emphasize the importance of medical therapy to reduce blood pressure in patients with renovascular hypertension, with PTRA without stenting being the treatment of choice for fibromuscular dysplasia 1.

From the Research

Role of Renal Angioplasty in ESRD Patients

• Renal angioplasty is considered a treatment option for patients with End-Stage Renal Disease (ESRD) caused by renal artery stenosis 2, 3, 4.
• The procedure involves percutaneous transluminal angioplasty and stent implantation to improve blood flow to the kidneys 2, 5.
• Studies have shown that renal angioplasty can improve blood pressure control and renal function in some patients, but the long-term benefits are still uncertain 3, 6, 4.
• Patient selection is crucial to maximize the potential benefits of renal angioplasty, with patients having refractory hypertension or progressive renal failure being considered for the procedure 6.

Indications for Renal Angioplasty

• Patients with recent deterioration in renal function, bilateral renal artery stenosis, or stenosis to a single functioning kidney may benefit from renal angioplasty 4.
• Those with flash pulmonary edema, advanced chronic renal failure, or ESRD may also be considered for the procedure 4.
• Patients who have reversible azotemia during angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor antagonist (ARB) therapy may also be candidates for renal angioplasty 4.

Outcomes and Complications

• Renal angioplasty has been shown to have a high technical success rate, with a low complication rate and good long-term patency 5.
• However, postprocedural deterioration of renal function is a concern, and may occur in 20 to 40% of patients 5.
• Atheroembolism is a potential cause of this deterioration, and the use of protection devices may help reduce the incidence of end-organ complications 5.