Hypertension, Renovascular

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