Medscape is available in 5 Language Editions – Choose your Edition here.


Renal Artery Stenosis

  • Author: Bruce S Spinowitz, MD, FACP; Chief Editor: Vecihi Batuman, MD, FACP, FASN  more...
Updated: Jul 18, 2016


Specialists have known for a long time that renal artery stenosis (RAS) is the major cause of renovascular hypertension and that it may account for 1-10% of the 50 million people in the United States who have hypertension.

Apart from its role in the pathogenesis of hypertension, renal artery stenosis is also being increasingly recognized as an important cause of chronic renal insufficiency and end-stage renal disease. In older individuals, atherosclerosis is by far the most common etiology of renal artery stenosis.[1, 2] As the renal artery lumen progressively narrows, renal blood flow decreases. Eventually,the decreased perfusion compromises renal function and structure.

With the increase in the elderly population and the possible increase in the prevalence of renal artery stenosis and ischemic nephropathy, clinicians dealing with renovascular disease (RVD) need noninvasive diagnostic tools and effective therapeutic measures to resolve the problem successfully. This article explores the natural history of this disorder, the value of a variety of invasive and noninvasive diagnostic procedures, and the consequence of allowing the artery to remain obstructed versus reversing renal artery occlusion.

For patient education information, see the Cholesterol Center, as well as Chronic Kidney Disease, High Cholesterol, Cholesterol FAQs, and Atorvastatin (Lipitor).



In patients with atherosclerosis, the initiator of endothelial injury is not clear; however, dyslipidemia, hypertension, cigarette smoking, diabetes mellitus, viral infection, immune injury, and increased homocysteine levels may contribute to endothelial injury. In the atherosclerotic lesion site, endothelium permeability to plasma macromolecules (eg, low-density lipoprotein [LDL]) increases, turnover of endothelial cells and smooth muscle cells increases, and intimal macrophages increase. When atherogenic lipoproteins exceed certain critical levels, the mechanical forces may enhance lipoprotein insudation in these regions, leading to early atheromatous lesions.

Renal blood flow is 3- to 5-fold greater than the perfusion to other organs because it drives glomerular capillary filtration. Both glomerular capillary hydrostatic pressure and renal blood flow are important determinants of the glomerular filtration rate (GFR).[3]

In patients with renal artery stenosis, the chronic ischemia produced by the obstruction of renal blood flow leads to adaptive changes in the kidney that are more pronounced in the tubular tissue. These changes include atrophy with decreased tubular cell size, patchy inflammation and fibrosis, tubulosclerosis, atrophy of the glomerular capillary tuft, thickening and duplication of the Bowman capsule, and intrarenal arterial medial thickening.

In patients with renal artery stenosis, the GFR is dependent on angiotensin II and other modulators that maintain the autoregulation system between the afferent and efferent arteries and can fail to maintain the GFR when renal perfusion pressure drops below 70-85 mm Hg. Significant functional impairment of autoregulation, leading to a decrease in the GFR, is not likely to be observed until arterial luminal narrowing exceeds 50%.

The degree of renal artery stenosis that would justify any attempt at either surgical intervention or radiologic intervention is not known. One study suggested that a ratio of pressure, measured distal to renal artery stenosis, less than 90% relative to aortic pressure, was associated with significant renin release from the affected kidney, renin being measured in the ipsilateral renal vein. This might be useful as a functional measurement of significant renovascular stenosis leading to hypertension and, thus, a marker of greater likelihood of benefit from angioplasty and stenting.[4, 5]



Risk factors associated with ischemic renal disease (IRD) are as follows:

  • Hypertension: Of patients with IRD, 35% can be normotensive
  • Advanced age: Numerous cases occur in persons aged 60-69 years; incidence increases in persons older than 70 years
  • Renal insufficiency
  • Extrarenal atherosclerosis
  • Diabetes mellitus
  • Smoking


United States

Studies suggest that ischemic nephropathy may be responsible for 5-22% of advanced renal disease in all patients older than 50 years.



The consequences of renal artery stenosis are hypertension, which may be particularly difficult to control or may require multiple antihypertensive agents (with increased adverse effects), and progressive loss of renal function (ischemic nephropathy).

In addition, the discovery of atherosclerotic RVD frequently occurs in the setting of generalized vascular disease (ie, cerebral, cardiac, peripheral), with the co-morbidity associated with disease in those vascular beds. Thus, any therapeutic intervention for renal artery stenosis should logically take into account the underlying prognosis associated with these co-morbidities.

Race-, Sex-, and Age-related Variances

RVD is less common in African Americans. The incidence rate in two studies of patients with severe hypertension was 27-45% in whites compared to 8-19% in African Americans.[6]

Although the incidence of atherosclerotic RVD is independent of sex, Crowley et al showed that female sex (as well as older age, elevated serum creatinine level, coronary artery disease, peripheral vascular disease, hypertension, and cerebrovascular disease) is an independent predictor of RVD progression.[7]

In 1964, Holley et al reported data from 295 consecutive autopsies performed in their institution during a 10-month period.[8] The mean age at death was 61 years. The prevalence rate of renal artery stenosis was 27% of 256 cases identified as having history of hypertension, while 56% showed significant stenosis (>50% luminal narrowing). In normotensive patients, 17% had severe renal artery stenosis (> 80% luminal narrowing). In those older than 70 years, 62% had severe renal artery stenosis.

Another similar autopsy study reported similar results, with 5% of patients older than 64 years showing severe stenosis; this figure increased to 18% for patients aged 65-74 years and 42% for patients older than 75 years.

Contributor Information and Disclosures

Bruce S Spinowitz, MD, FACP Clinical Professor of Medicine, Weill Medical College of Cornell University; School of Medicine; Associate Chairman, Associate Director and Attending Physician, Department of Medicine, Division of Nephrology, New York Hospital Medical Center Queens; Associate, Nephrology Associates, PC

Bruce S Spinowitz, MD, FACP is a member of the following medical societies: American College of Physicians, International Society for Peritoneal Dialysis, Renal Physicians Association, American Society of Nephrology, International Society of Nephrology

Disclosure: Received grant/research funds from AMAG Pharmaceuticals for independent contractor; Received grant/research funds from Amgen for independent contractor; Received grant/research funds from Vifor for independent contractor; Received grant/research funds from Hospira for independent contractor; Received grant/research funds from Relypsa for independent contractor; Received grant/research funds from Akebia for independent contractor; Received grant/research funds from ZS Pharma for none.


Joanna Rodriguez, MD 

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eleanor Lederer, MD, FASN Professor of Medicine, Chief, Nephrology Division, Director, Nephrology Training Program, Director, Metabolic Stone Clinic, Kidney Disease Program, University of Louisville School of Medicine; Consulting Staff, Louisville Veterans Affairs Hospital

Eleanor Lederer, MD, FASN is a member of the following medical societies: American Association for the Advancement of Science, International Society of Nephrology, American Society for Biochemistry and Molecular Biology, American Federation for Medical Research, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, Kentucky Medical Association, National Kidney Foundation, Phi Beta Kappa

Disclosure: Received grant/research funds from Dept of Veterans Affairs for research; Received salary from American Society of Nephrology for asn council position; Received salary from University of Louisville for employment; Received salary from University of Louisville Physicians for employment; Received contract payment from American Physician Institute for Advanced Professional Studies, LLC for independent contractor; Received contract payment from Healthcare Quality Strategies, Inc for independent cont.

Chief Editor

Vecihi Batuman, MD, FACP, FASN Huberwald Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Renal Section, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, International Society of Nephrology

Disclosure: Nothing to disclose.


Donald A Feinfeld, MD, FACP, FASN Consulting Staff, Division of Nephrology and Hypertension, Beth Israel Medical Center

Disclosure: Nothing to disclose.

  1. Chrysochou C, Kalra PA. Current Management of Atherosclerotic Renovascular Disease - What Have We Learned from ASTRAL?. Nephron Clin Pract. 2010 Feb 20. 115(1):c73-c81. [Medline]. [Full Text].

  2. Plouin PF, Bax L. Diagnosis and treatment of renal artery stenosis. Nat Rev Nephrol. 2010 Mar. 6(3):151-9. [Medline].

  3. Iida M, Maeda H, Yamamoto M, et al. Association of renal artery stenosis with aortic jet velocity in hypertensive patients with aortic valve sclerosis. Am J Hypertens. 2010 Feb. 23(2):197-201. [Medline].

  4. De Bruyne B, Manoharan G, Pijls NH, et al. Assessment of renal artery stenosis severity by pressure gradient measurements. J Am Coll Cardiol. 2006 Nov 7. 48(9):1851-5. [Medline].

  5. Simon JF. Stenting atherosclerotic renal arteries: time to be less aggressive. Cleve Clin J Med. 2010 Mar. 77(3):178-89. [Medline]. [Full Text].

  6. Jazrawi A, Darda S, Burke P, et al. Is race a risk factor for the development of renal artery stenosis?. Cardiol Res Pract. 2009. 2009:817987. [Medline]. [Full Text].

  7. Crowley JJ, Santos RM, Peter RH, et al. Progression of renal artery stenosis in patients undergoing cardiac catheterization. Am Heart J. 1998 Nov. 136(5):913-8. [Medline].

  8. Holley KE, Hunt JC, Brown AL Jr, et al. Renal artery stenosis. A clinical-pathologic study in normotensive and hypertensive patients. Am J Med. 1964 Jul. 37:14-22.

  9. Levey AS, Bosch JP, Lewis JB, et al. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med. 1999 Mar 16. 130(6):461-70. [Medline].

  10. 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 Feb 8. 344(6):410-7. [Medline].

  11. Olbricht CJ, Paul K, Prokop M, et al. Minimally invasive diagnosis of renal artery stenosis by spiral computed tomography angiography. Kidney Int. 1995 Oct. 48(4):1332-7. [Medline].

  12. Broome DR, Girguis MS, Baron PW, et al. Gadodiamide-associated nephrogenic systemic fibrosis: why radiologists should be concerned. AJR Am J Roentgenol. 2007 Feb. 188(2):586-92. [Medline]. [Full Text].

  13. Garovic VD, Achauer MA, Kittner T, et al. Comparison of gadodiamide-enhanced MR angiography to intraarterial digital subtraction angiography for evaluation of renal artery stenosis: results of a phase III multicenter trial. J Magn Reson Imaging. 2010 Feb. 31(2):390-7. [Medline].

  14. Loubeyre P, Trolliet P, Cahen R, et al. MR angiography of renal artery stenosis: value of the combination of three-dimensional time-of-flight and three-dimensional phase-contrast MR angiography sequences. AJR Am J Roentgenol. 1996 Aug. 167(2):489-94. [Medline].

  15. Vasbinder GB, Nelemans PJ, Kessels AG, et al. Accuracy of computed tomographic angiography and magnetic resonance angiography for diagnosing renal artery stenosis. Ann Intern Med. 2004 Nov 2. 141(9):674-82; discussion 682. [Medline].

  16. Andersson Z, Thisted E, Andersen UB. Renal Branch Artery Stenosis: a Diagnostic Challenge? A Case Report with Review of the Literature. Urology. 2016 Jun 28. 96 (1):205-9. [Medline].

  17. Gilfeather M, Yoon HC, Siegelman ES, et al. Renal artery stenosis: evaluation with conventional angiography versus gadolinium-enhanced MR angiography. Radiology. 1999 Feb. 210(2):367-72. [Medline].

  18. Gross CM, Kramer J, Weingartner O, et al. Determination of renal arterial stenosis severity: comparison of pressure gradient and vessel diameter. Radiology. 2001 Sep. 220(3):751-6.

  19. Cooper CJ, Murphy TP. Is renal artery stenting the correct treatment of renal artery stenosis? The case for renal artery stenting for treatment of renal artery stenosis. Circulation. 2007 Jan 16. 115(2):263-9; discussion 270. [Medline].

  20. Dworkin LD, Jamerson KA. Is renal artery stenting the correct treatment of renal artery stenosis? Case against angioplasty and stenting of atherosclerotic renal artery stenosis. Circulation. 2007 Jan 16. 115(2):271-6; discussion 276. [Medline].

  21. Levin A, Linas S, Luft FC, et al. Controversies in renal artery stenosis: a review by the American Society of Nephrology Advisory Group on Hypertension. Am J Nephrol. 2007. 27(2):212-20. [Medline].

  22. Morris GC, DeBakey ME, Cooley DA. Surgical Treatment of renal failure of renovascular origin. JAMA. 1962. 182:609-12.

  23. Rimmer JM, Gennari FJ. Atherosclerotic renovascular disease and progressive renal failure. Ann Intern Med. 1993 May 1. 118(9):712-9. [Medline].

  24. Reilly JM, Rubin BG, Thompson RW, et al. Revascularization of the solitary kidney: a challenging problem in a high risk population. Surgery. 1996 Oct. 120(4):732-6; discussion 736-7. [Medline].

  25. Ziegelbaum M, Novick AC, Hayes J, et al. Management of renal arterial disease in the elderly patient. Surg Gynecol Obstet. 1987 Aug. 165(2):130-4. [Medline].

  26. Erdoes LS, Berman SS, Hunter GC, et al. Comparative analysis of percutaneous transluminal angioplasty and operation for renal revascularization. Am J Kidney Dis. 1996 Apr. 27(4):496-503. [Medline].

  27. van Jaarsveld BC, Krijnen P, Pieterman H, et al. The effect of balloon angioplasty on hypertension in atherosclerotic renal-artery stenosis. Dutch Renal Artery Stenosis Intervention Cooperative Study Group. N Engl J Med. 2000 Apr 6. 342(14):1007-14. [Medline].

  28. 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 Jan 23. 353(9149):282-6. [Medline].

  29. Ives NJ, Wheatley K, Stowe RL, et al. Continuing uncertainty about the value of percutaneous revascularization in atherosclerotic renovascular disease: a meta-analysis of randomized trials. Nephrol Dial Transplant. 2003 Feb. 18(2):298-304. [Medline].

  30. Textor SC. Ischemic nephropathy: where are we now?. J Am Soc Nephrol. 2004 Aug. 15(8):1974-82. [Medline].

  31. Plouin PF. Stable patients with atherosclerotic renal artery stenosis should be treated first with medical management. Am J Kidney Dis. 2003 Nov. 42(5):851-7. [Medline].

  32. 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 Jun 16. 150(12):840-8, W150-1. [Medline]. [Full Text].

  33. Wheatley K, Ives N, Gray R, et al. Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med. 2009 Nov 12. 361(20):1953-62. [Medline].

  34. Simon JF. Stenting atherosclerotic renal arteries: time to be less aggressive. Cleve Clin J Med. 2010 Mar. 77(3):178-89. [Medline].

  35. Safian RD, Textor SC. Renal-artery stenosis. N Engl J Med. 2001 Feb 8. 344(6):431-42. [Medline].

  36. Cooper CJ, Murphy TP, Cutlip DE, Jamerson K, Henrich W, Reid DM, et al. Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med. 2014 Jan 2. 370(1):13-22. [Medline].

  37. Riaz IB, Husnain M, Riaz H, Asawaeer M, Bilal J, Pandit A, et al. Meta-analysis of revascularization versus medical therapy for atherosclerotic renal artery stenosis. Am J Cardiol. 2014 Oct 1. 114(7):1116-23. [Medline].

  38. Ritchie J, Green D, Chrysochou C, Chalmers N, Foley RN, Kalra PA. High-risk clinical presentations in atherosclerotic renovascular disease: prognosis and response to renal artery revascularization. Am J Kidney Dis. 2014 Feb. 63(2):186-97. [Medline].

  39. Textor SC, Misra S, Oderich GS. Percutaneous revascularization for ischemic nephropathy: the past, present, and future. Kidney Int. 2013 Jan. 83(1):28-40. [Medline]. [Full Text].

  40. Dejani H, Eisen TD, Finkelstein FO. Revascularization of renal artery stenosis in patients with renal insufficiency. Am J Kidney Dis. 2000 Oct. 36(4):752-8. [Medline].

  41. Yang YK, Zhang Y, Meng X, Yang KQ, Jiang XJ, Wu HY, et al. Clinical characteristics and treatment of renal artery fibromuscular dysplasia with percutaneous transluminal angioplasty: a long-term follow-up study. Clin Res Cardiol. 2016 Jun 6. [Medline].

  42. [Guideline] Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH, et al. Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Apr 2. 127 (13):1425-43. [Medline]. [Full Text].

  43. [Guideline] European Stroke Organisation, Tendera M, Aboyans V, et al. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2011 Nov. 32 (22):2851-906. [Medline]. [Full Text].

  44. [Guideline] Parikh SA, Shishehbor MH, Gray BH, White CJ, Jaff MR. SCAI expert consensus statement for renal artery stenting appropriate use. Catheter Cardiovasc Interv. 2014 Dec 1. 84 (7):1163-71. [Medline]. [Full Text].

  45. Bianchi S, Bigazzi R, Caiazza A, et al. A controlled, prospective study of the effects of atorvastatin on proteinuria and progression of kidney disease. Am J Kidney Dis. 2003 Mar. 41(3):565-70. [Medline].

  46. Schreiber MJ, Pohl MA, Novick AC. The natural history of atherosclerotic and fibrous renal artery disease. Urol Clin North Am. 1984 Aug. 11(3):383-92. [Medline].

  47. Krijnen P, Van Jaarsveld BC, Deinum J, et al. Which patients with hypertension and atherosclerotic renal artery stenosis benefit from immediate intervention?. J Hum Hypertens. 2004 Feb. 18(2):91-6. [Medline].

  48. Lao D, Parasher PS, Cho KC, Yeghiazarians Y. Atherosclerotic renal artery stenosis--diagnosis and treatment. Mayo Clin Proc. 2011 Jul. 86(7):649-57. [Medline]. [Full Text].

  49. Main J. When should atheromatous renal artery stenosis be considered? A guide for the general physician. Clin Med. 2003 Nov-Dec. 3(6):520-5. [Medline].

All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.