Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ 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 ++... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Download the Access App: iOS | Android Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.