Renovascular Hypertension Clinical Presentation

  • Author: Rebecca J Schmidt, DO, FACP, FASN; Chief Editor: Vecihi Batuman, MD, FACP, FASN   more...
 
Updated: Sep 4, 2009
 

History

Clinical risk factors include a history of hypertension with azotemia (serum creatinine level >1.5 mg/dL) and modest proteinuria (levels < 1.5 g/d) or progressive renal insufficiency, accelerated or malignant hypertension, severe hypertension (diastolic blood pressure >120 mm Hg), hypertension with an asymmetric kidney, paradoxical worsening of hypertension with diuretic therapy, and hypertension refractory to standard therapy.

  • Onset of hypertension occurring in patients younger than 30 years without risk factors
  • Abrupt onset of severe (stage II) hypertension (greater than 160/100 in patients older than 55 years)
  • Severe or resistant hypertension despite appropriately dosed multidrug (>3 agents) antihypertensive therapy
  • Abrupt increase in blood pressure over previously stable baseline in patients with previously well-controlled essential hypertension as well as patients with known RAS
  • Negative family history for hypertension
  • Smoking tobacco products
  • Acute sustained rise in serum creatinine levels with ACE inhibition
  • Unprovoked hypokalemia (serum potassium level < 3.6 mEq/L, often associated with metabolic alkalosis)
  • Symptoms of atherosclerotic disease elsewhere in the presence of moderate-to-severe hypertension, particularly in patients older than 50 years
  • Recurrent pulmonary edema in the setting of moderate-to-severe hypertension
  • Moderate-to-severe hypertension in a patient with an unexplained atrophic kidney, asymmetric kidneys of greater than 1.5 cm difference or diffuse atherosclerosis
Next

Physical

Findings suggestive of long-standing hypertension may or may not be evident upon physical examination.

  • Recurrent flash pulmonary edema or unexplained episodes of congestive heart failure
  • Advanced funduscopic changes
  • Abdominal bruit
    • A clear abdominal bruit is heard in 46% of patients with RVHT.
    • It also is heard in 9% of patients with essential hypertension; however, innocent bruits are common in younger individuals.
    • Systolic-diastolic bruits in combination with hypertension are suggestive of RVHT.
Previous
Next

Causes

  • Overall, approximately two thirds of RVHT cases are caused by atherosclerotic disease and one third are caused by fibromuscular dysplasia or other congenital disorders.
  • Other clinical entities that may be associated with RVHT include cholesterol embolic disease, acute arterial thrombosis or embolism, aortic dissection, renal arterial trauma, arterial aneurysm, arteriovenous malformation of the renal artery, and polyarteritis nodosa.
Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Rebecca J Schmidt, DO, FACP, FASN  Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine

Rebecca J Schmidt, DO, FACP, FASN is a member of the following medical societies: American College of Osteopathic Internists, American College of Physicians, American Medical Association, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation, Renal Physicians Association, and West Virginia State Medical Association

Disclosure: Abbott Grant/research funds Speaking and teaching; Genzyme Honoraria Consulting; Amgen Honoraria Speaking and teaching; Ortho Biotech Honoraria Speaking and teaching

Coauthor(s)

Sandeep S Soman, MBBS, MD, DNB  Senior Staff Physician, Department of Internal Medicine, Division of Nephrology and Hypertension, Henry Ford Hospital

Sandeep S Soman, MBBS, MD, DNB is a member of the following medical societies: American College of Physicians, American Medical Association, and American Society of Nephrology

Disclosure: Nothing to disclose.

Specialty Editor Board

L Michael Prisant, MD, FACC  Director of Hypertension and Clinical Pharmacology Unit, Professor of Medicine, Department of Medicine, Medical College of Georgia

L Michael Prisant, MD, FACC is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Clinical Pharmacology, American College of Forensic Examiners, American College of Physicians, American Heart Association, and American Medical Association

Disclosure: Abbott Grant/research funds Investigator; Boehringer-Ingelheim Grant/research funds Other; Eli Lilly None Investigator; Novartis None Investigator; Abbott, Boehringer-Ingelheim, Forest, Gilead, Merck, Merck/Schering-Plough, Novartis, Oscient, Sciele, SunTech Medical Consulting fee Consulting; Abbott, Boehringer-Ingelheim, Merck, Merck/Schering-Plough, Novartis, Oscient Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

George R Aronoff, MD  Director, Professor, Departments of Internal Medicine and Pharmacology, Section of Nephrology, Kidney Disease Program, University of Louisville School of Medicine

George R Aronoff, MD is a member of the following medical societies: American Federation for Medical Research, American Society of Nephrology, Kentucky Medical Association, and National Kidney Foundation

Disclosure: Nothing to disclose.

Chief Editor

Vecihi Batuman, MD, FACP, FASN  Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, 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, and International Society of Nephrology

Disclosure: Nothing to disclose.

References

  1. Slanina M, Zizka J, Klzo L, et al. Contrast-enhanced MR angiography utilizing parallel acquisition techniques in renal artery stenosis detection. Eur J Radiol. Aug 9 2009;[Medline].

  2. Nchimi A, Brisbois D, Materne R, et al. Free-breathing accelerated gadolinium-enhanced MR angiography in the diagnosis of renovascular disease. AJR Am J Roentgenol. Jun 2009;192(6):1531-7. [Medline].

  3. Textor SC, Lerman L, McKusick M. The uncertain value of renal artery interventions: where are we now?. JACC Cardiovasc Interv. Mar 2009;2(3):175-82. [Medline].

  4. Jensen G, Annerstedt M, Klingenstierna H, et al. Survival and quality of life after renal angioplasty: a five-year follow-up study. Scand J Urol Nephrol. 2009;43(3):236-41. [Medline].

  5. Jokhi PP, Ramanathan K, Walsh S, et al. Experience of stenting for atherosclerotic renal artery stenosis in a cardiac catheterization laboratory: technical considerations and complications. Can J Cardiol. Aug 2009;25(8):e273-8. [Medline].

  6. Leesar MA, Varma J, Shapira A, et al. Prediction of hypertension improvement after stenting of renal artery stenosis: comparative accuracy of translesional pressure gradients, intravascular ultrasound, and angiography. J Am Coll Cardiol. Jun 23 2009;53(25):2363-71. [Medline].

  7. Aurell M, Jensen G. Treatment of renovascular hypertension. Nephron. 1997;75(4):373-83. [Medline].

  8. Bloch MJ, Basile J. Clinical insights into the diagnosis and management of renovascular disease. An evidence-based review. Minerva Med. Oct 2004;95(5):357-73. [Medline].

  9. Bloch MJ, Basile J. The diagnosis and management of renovascular disease: a primary care perspective. Part I. Making the diagnosis. J Clin Hypertens (Greenwich). May-Jun 2003;5(3):210-8. [Medline].

  10. Bloch MJ, Basile J. The diagnosis and management of renovascular disease: a primary care perspective. Part II. Issues in management. J Clin Hypertens (Greenwich). Jul-Aug 2003;5(4):261-8. [Medline].

  11. Canzanello VJ, Textor SC. Noninvasive diagnosis of renovascular disease. Mayo Clin Proc. Dec 1994;69(12):1172-81. [Medline].

  12. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. May 21 2003;289(19):2560-72. [Medline].

  13. Conlon PJ, O'Riordan E, Kalra PA. New insights into the epidemiologic and clinical manifestations of atherosclerotic renovascular disease. Am J Kidney Dis. Apr 2000;35(4):573-87. [Medline].

  14. Greco BA, Breyer JA. Atherosclerotic ischemic renal disease. Am J Kidney Dis. Feb 1997;29(2):167-87. [Medline].

  15. Hacklander T, Mertens H, Stattaus J, Lurken M, Lerch H, Altenburg A, et al. Evaluation of renovascular hypertension: comparison of functional MRI and contrast-enhanced MRA with a routinely performed renal scintigraphy and DSA. J Comput Assist Tomogr. Nov-Dec 2004;28(6):823-31. [Medline].

  16. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation. Mar 21 2006;113(11):e463-654. [Medline]. [Full Text].

  17. Kaplan NM. Renal vascular hypertension. In: Clinical Hypertension. 7th ed. Baltimore: Lippincott Williams & Wilkins; 1998:301-21.

  18. Leung DA, Hoffmann U, Pfammatter T, Hany TF, Rainoni L, Hilfiker P, et al. Magnetic resonance angiography versus duplex sonography for diagnosing renovascular disease. Hypertension. Feb 1999;33(2):726-31. [Medline].

  19. Ploth DW. Renovascular hypertension. In: Jacobson H, Striker G, Klahr S, eds. The Principles and Practice of Nephrology. 2nd ed. Philadelphia: BC Decker; 1995:379-86.

  20. Rabbia C, Valpreda S. Duplex scan sonography of renal artery stenosis. Int Angiol. Jun 2003;22(2):101-15. [Medline].

  21. Radermacher J, Haller H. The right diagnostic work-up: investigating renal and renovascular disorders. J Hypertens Suppl. May 2003;21 Suppl 2:S19-24. [Medline].

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

  23. Soulez G, Oliva VL, Turpin S, Lambert R, Nicolet V, Therasse E. Imaging of renovascular hypertension: respective values of renal scintigraphy, renal Doppler US, and MR angiography. Radiographics. Sep-Oct 2000;20(5):1355-68; discussion 1368-72. [Medline].

  24. Spitalewitz S, Reiser I. Renovascular hypertension: diagnosis and treatment. In: Oparil S, Weber MA, eds. Hypertension: A Companion to Brenner and Rector's The Kidney. Philadelphia: WB Saunders Co; 2000:662-74.

  25. Textor SC. Pitfalls in imaging for renal artery stenosis. Ann Intern Med. Nov 2 2004;141(9):730-1. [Medline].

  26. Tullis MJ, Caps MT, Zierler RE, Bergelin RO, Polissar N, Cantwell-Gab K, et al. Blood pressure, antihypertensive medication, and atherosclerotic renal artery stenosis. Am J Kidney Dis. Apr 1999;33(4):675-81. [Medline].

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

  28. Working Group on Renovascular Hypertension. Detection, evaluation, and treatment of renovascular hypertension. Final report. Working Group on Renovascular Hypertension. Arch Intern Med. May 1987;147(5):820-9. [Medline].

 
Previous
Next
 
Magnetic resonance angiography (MRA) showing renal artery stenosis. Courtesy of Patricia Stoltzfus, MD, Chief of Interventional Radiology, West Virginia University.
Proposed pathogenesis of renovascular hypertension.
Angiogram showing bilateral renal artery stenosis. Courtesy of Department of Radiology, Henry Ford Hospital.
After percutaneous transluminal angioplasty (right renal artery). Courtesy of Department of Radiology, Henry Ford Hospital.
After percutaneous transluminal angioplasty and stent placement (left renal artery). Courtesy of Department of Radiology, Henry Ford Hospital.
Close-up of the Palmaz stent. Courtesy of Department of Radiology, Henry Ford Hospital.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.