Electrolyte Blood Press.  2010 Dec;8(2):87-91.

Atherosclerotic Renovascular Hypertension : Lessons from Recent Clinical Studies

• Chung W
• Kim S

Abstract

Atherosclerotic renovascular hypertension is a form of secondary hypertension due to renal artery stenosis. After the introduction of medical therapy such as with statins and angiotensin blocking agents, it has been considered a very slowly progressive disease. In the 1990s, surgical methods were compared to radiological intervention and showed no additional benefits. Recent clinical data also demonstrate that in cases of relatively stable atherosclerotic renovascular disease, medical therapy is as effective as other interventions with regard to patient outcomes. In this paper the recent clinical outcomes are reviewed.

Keyword

atherosclerosis; renal artery obstruction; hypertension

MeSH Terms

Angiotensins
Atherosclerosis
Humans
Hypertension
Hypertension, Renovascular
Renal Artery Obstruction
Angiotensins

Figure

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  Fig. 1 Mechanisms of Renal Damage Associated with Atherosclerotic Renal Artery Stenosis. These mechanisms include an interaction among increased oxidative stress, immune responses, inflammation, immune responses, and angiotensin II/endothelin, which impair renal function, induce endothelial and epithelial dysfunction and injury, and may lead to irreversible scarring. Ox LDL, oxidized low-density lipoprotein cholesterol.*Modified from the study of Chade AR et al. Ref. 14.

Reference

1. Hansen KJ, Edwards MS, Craven TE, et al. Prevalence of renovascular disease in the elderly: a population-based study. J Vasc Surg. 2002; 36:443–451. PMID: 12218965.

2. Conlon PJ, Little MA, Pieper K, Mark DB. Severity of renal vascular disease predicts mortality in patients undergoing coronary angiography. Kidney Int. 2001; 60:1490–1497. PMID: 11576364.

3. Galaria II, Surowiec SM, Rhodes JM, et al. Percutaneous and open renal revascularizations have equivalent long-term functional outcomes. Ann Vasc Surg. 2005; 19:218–228. PMID: 15735947.

4. Kennedy DJ, Colyer WR, Brewster PS, et al. Renal insufficiency as a predictor of adverse events and mortality after renal artery stent placement. Am J Kidney Dis. 2003; 42:926–935. PMID: 14582036.

5. Beutler JJ, Van Ampting JM, Van De Ven PJ, et al. Long-term effects of arterial stenting on kidney function for patients with ostial atherosclerotic renal artery stenosis and renal insufficiency. J Am Soc Nephrol. 2001; 12:1475–1481. PMID: 11423576.

6. van de Ven PJ, Kaatee R, Beutler JJ, et al. Arterial stenting and balloon angioplasty in ostial atherosclerotic renovascular disease: a randomised trial. Lancet. 1999; 353:282–286. PMID: 9929021.

7. Bax L, Woittiez AJ, Kouwenberg HJ, et al. Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function: a randomized trial. Ann Intern Med. 2009; 150:840–848. PMID: 19414832.

8. Wheatley K, Ives N, Gray R, et al. Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med. 2009; 361:1953–1962. PMID: 19907042.

9. Axelrod DA, Fendrick AM, Carlos RC, et al. Percutaneous stenting of incidental unilateral renal artery stenosis: decision analysis of costs and benefits. J Endovasc Ther. 2003; 10:546–556. PMID: 12932167.

10. Caps MT, Perissinotto C, Zierler RE, et al. Prospective study of atherosclerotic disease progression in the renal artery. Circulation. 1998; 98:2866–2872. PMID: 9860789.

11. Cheung CM, Patel A, Shaheen N, et al. The effects of statins on the progression of atherosclerotic renovascular disease. Nephron Clin Pract. 2007; 107:C35–C42. PMID: 17713349.

12. Pearce JD, Craven BL, Craven TE, et al. Progression of atherosclerotic renovascular disease: A prospective population-based study. J Vasc Surg. 2006; 44:955–962. discussion 962-953. PMID: 16982169.

13. Textor SC. Atherosclerotic renal artery stenosis: how big is the problem, and what happens if nothing is done? J Hypertens Suppl. 2005; 23:S5–S13. PMID: 16251847.

14. Chade AR, Lerman A, Lerman LO. Kidney in early atherosclerosis. Hypertension. 2005; 45:1042–1049. PMID: 15897370.

15. Meier P, Rossert J, Plouin PF, Burnier M. Atherosclerotic renovascular disease: beyond the renal artery stenosis. Nephrol Dial Transplant. 2007; 22:1002–1006. PMID: 17210599.

16. Wright JR, Shurrab AE, Cheung C, et al. A prospective study of the determinants of renal functional outcome and mortality in atherosclerotic renovascular disease. Am J Kidney Dis. 2002; 39:1153–1161. PMID: 12046025.

17. Radermacher J, Chavan A, Bleck J, et al. Use of Doppler ultrasonography to predict the outcome of therapy for renal-artery stenosis. N Engl J Med. 2001; 344:410–417. PMID: 11172177.

18. Chrysochou C, Cheung CM, Durow M, et al. Proteinuria as a predictor of renal functional outcome after revascularization in atherosclerotic renovascular disease (ARVD). QJM. 2009; 102:283–288. PMID: 19202165.

19. Simon JF. Stenting atherosclerotic renal arteries: time to be less aggressive. Cleve Clin J Med. 2010; 77:178–189. PMID: 20200168.

20. Hiramoto J, Hansen KJ, Pan XM, Edwards MS, Sawhney R, Rapp JH. Atheroemboli during renal artery angioplasty: an ex vivo study. J Vasc Surg. 2005; 41:1026–1030. PMID: 15944605.

21. Hackam DG, Duong-Hua ML, Mamdani M, et al. Angiotensin inhibition in renovascular disease: a population-based cohort study. Am Heart J. 2008; 156:549–555. PMID: 18760140.

22. Cooper CJ, Murphy TP, Matsumoto A, et al. Stent revascularization for the prevention of cardiovascular and renal events among patients with renal artery stenosis and systolic hypertension: rationale and design of the CORAL trial. Am Heart J. 2006; 152:59–66. PMID: 16824832.

23. Rocha-Singh KJ, Eisenhauer AC, Textor SC, et al. Atherosclerotic Peripheral Vascular Disease Symposium II: intervention for renal artery disease. Circulation. 2008; 118:2873–2878. PMID: 19106410.

24. Pickering TG, Herman L, Devereux RB, et al. Recurrent pulmonary oedema in hypertension due to bilateral renal artery stenosis: treatment by angioplasty or surgical revascularisation. Lancet. 1988; 2:551–552. PMID: 2900930.

25. Messina LM, Zelenock GB, Yao KA, Stanley JC. Renal revascularization for recurrent pulmonary edema in patients with poorly controlled hypertension and renal insufficiency: a distinct subgroup of patients with arteriosclerotic renal artery occlusive disease. J Vasc Surg. 1992; 15:73–80. discussion 80-82. PMID: 1728693.

26. Bloch MJ, Trost DW, Pickering TG, Sos TA, August P. Prevention of recurrent pulmonary edema in patients with bilateral renovascular disease through renal artery stent placement. Am J Hypertens. 1999; 12:1–7. PMID: 10075377.