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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Age 30 or after age 55

  • Abdominal or flank systolic and diastolic bruits, or evidence of peripheral vascular disease

  • Unilateral small kidney on any imaging study

  • Hypertension resistant to 3 medications

  • Worsening renal function after an angiotensin-converting enzyme inhibitor

  • Elevated plasma renin activity with or without captopril administration

  • Imaging evidence of renal artery occlusive disease

GENERAL CONSIDERATIONS

  • Renal vascular disease is an unusual cause of hypertension but is potentially curable

  • Renal vascular hypertension usually results from obstruction of 1 main artery in 1 kidney

  • The most common cause in women < age 30 is fibromuscular hyperplasia

  • The most common cause in men > age 55 is atherosclerosis

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • No specific symptoms or signs

PHYSICAL EXAM FINDINGS

  • Advanced eye fundoscopic changes are common

  • Renal bruits may be heard

  • Evidence of other vascular disease

DIFFERENTIAL DIAGNOSIS

  • Essential hypertension

  • Renal parenchymal disease

  • Other causes of secondary hypertension

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • High plasma renin activity and plasma aldosterone levels

ELECTROCARDIOGRAPHY

  • Left heart chamber enlargement may be seen

IMAGING STUDIES

  • CT or magnetic resonance angiography of the renal arteries

DIAGNOSTIC PROCEDURES

  • Renal arteriogram is almost always diagnostic and can be followed by stenting if appropriate

TREATMENT

CARDIOLOGY REFERRAL

  • Refractory hypertension

  • Suspected cardiac disease

  • Planned renal artery stenting

HOSPITALIZATION CRITERIA

  • Complications of hypertension

  • Planned procedure

MEDICATIONS

  • Pharmacologic therapy if hypertension is mild or readily controlled

THERAPEUTIC PROCEDURES

  • Percutaneous angioplasty with or without stenting

SURGERY

  • Surgical repair or nephrectomy

MONITORING

  • Blood pressure

  • ECG in hospital as appropriate

DIET AND ACTIVITY

  • Low-sodium diet, limited alcohol intake

  • Exercise as tolerated

ONGOING MANAGEMENT

HOSPITAL DISCHARGE CRITERIA

  • Resolution of problem

  • Definitive procedure or surgery

FOLLOW-UP

  • One month, then 3 months, 6 months, yearly after procedure or surgery

COMPLICATIONS

  • Acute pulmonary edema

  • Rapid decline in renal function

  • Accelerated or malignant hypertension

  • Restenosis can occur after angioplasty or stenting

  • Persistent hypertension may occur after successful relief of arterial obstruction

PROGNOSIS

  • Excellent with correction of the vascular obstruction

PREVENTION

  • Preventive measures for atherosclerosis

RESOURCES

PRACTICE GUIDELINES
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