eMedicine Specialties > Nephrology > Hypertension and the Kidney

Renovascular Hypertension: Follow-up

Author: Rebecca J Schmidt, DO, FACP, FASN, Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine
Coauthor(s): Sandeep S Soman, MBBS, MD, DNB, Senior Staff Physician, Department of Internal Medicine, Division of Nephrology and Hypertension, Henry Ford Hospital
Contributor Information and Disclosures

Updated: Sep 4, 2009

Follow-up

Further Inpatient Care

  • Inpatient care usually is necessary for the management of hypertensive urgencies or emergencies associated with RVHT.
  • Timely diagnosis of RVHT and early intervention are required to prevent further ischemic end-organ damage to the kidney and other organs.

Further Outpatient Care

  • In addition to diagnosis and treatment of hypertension, renal function must be assessed and followed so that recognition of renal dysfunction is early and definitive intervention, when appropriate, can be instituted.

Transfer

  • The patient should be transferred to another facility when necessary testing to confirm or refute the diagnosis of RVHT or to assess the severity of a confirmed diagnosis of RVHT cannot be performed adequately at the current treating facility.
  • Additionally, the patient should be transferred to a tertiary care medical facility when necessary surgical treatments, such as renal artery bypass or renal artery transluminal angioplasty, must be performed and the current treating facility is not equipped for such procedures.

Deterrence/Prevention

  • Renal arterial atherosclerotic stenosis now is recognized as an important and fastest-growing cause of end-stage renal disease. Because preventing this form of renal failure is possible by performing an operation or angioplasty, identifying patients who may be at risk for renal ischemia by atherosclerosis is important. Even when renal function is impaired, relief of the stenosis, if achieved early enough, may result in dramatic improvement.
  • A clinically atypical course of hypertension developing in people older than 50 years, difficulty controlling long-standing hypertension that previously was easy to control, or an increase in creatinine level after administration of an ACE inhibitor all should prompt evaluation for renal arterial disease.
  • Deterioration of renal function in the setting of diffuse atherosclerosis but no proteinuria or known renal parenchymal disease, even in the absence of hypertension, is highly suggestive of renovascular disease.

Complications

  • Major complications of RVHT include end-organ damage from chronically uncontrolled hypertension and progressive renal failure, an important and indolent sequela of chronic renal ischemia.

Prognosis

  • The prognosis of patients with RVHT is difficult to ascertain and varies with the extent of the occlusive phenomena, the sensitivity of the individual to antihypertensive therapy, and the efficacy of surgical repair and/or angioplasty.
  • RVHT in the setting of chronic renal ischemia and consequent renal dysfunction has been linked to worse outcomes.

Patient Education

  • Education about hypertension should include information about the clinical features associated with RVHT (see Clinical) and information about the importance of good blood pressure control.

Miscellaneous

Medicolegal Pitfalls

  • Failure to recognize clues to the presence of RVHT that might lead to complications, such as stroke, renal failure, and cardiac decompensation
    • Recurrent and otherwise unexplained flash pulmonary edema or heart failure
    • Recalcitrant hypertension that previously was controlled easily
    • Hypertension that abruptly becomes more difficult to control and requires increased antihypertensive agents
    • Slowly increasing serum creatinine signifying the evolution of ischemic nephropathy
 


More on Renovascular Hypertension

Overview: Renovascular Hypertension
Differential Diagnoses & Workup: Renovascular Hypertension
Treatment & Medication: Renovascular Hypertension
Follow-up: Renovascular Hypertension
Multimedia: Renovascular Hypertension
References
Further Reading
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References

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Further Reading

Related eMedicine topics:
Angioplasty, Renal Artery
Fibromuscular Dysplasia
Hyperaldosteronism
Hypertension [Nephrology]
Hypertension [Ophthalmology]
Hypertension, Malignant
Renal Artery Stenosis
Renal Artery Stenosis/Renovascular Hypertension
Renovascular Hypertension, Surgical Treatment

Clinical guidelines:
 ACC/AHA 2005 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). American College of Cardiology Foundation - Medical Specialty Society
American Heart Association - Professional Association
Society for Cardiovascular Angiography and Interventions - Medical Specialty Society
Society for Vascular Medicine and Biology - Medical Specialty Society
Society for Vascular Surgery - Medical Specialty Society
Society of Interventional Radiology - Medical Specialty Society.  2005.  191 pages.  NGC:004740

ACR Appropriateness Criteria® renovascular hypertension. American College of Radiology - Medical Specialty Society.  1995 (revised 2007).  9 pages.  NGC:006003

The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. National Heart, Lung, and Blood Institute (U.S.) - Federal Government Agency [U.S.].  2004 Aug.  22 pages.  NGC:003761

VHA/DoD clinical practice guideline for the diagnosis and management of hypertension in the primary care setting. Department of Defense - Federal Government Agency [U.S.]
Department of Veterans Affairs - Federal Government Agency [U.S.]
Veterans Health Administration - Federal Government Agency [U.S.].  1999 May (revised 2004).  99 pages.  NGC:004198

Clinical trials:
Benefits of Medical Therapy Plus Stenting for Renal Atherosclerotic Lesions (CORAL)

Comparison of Best Medical Treatment Versus Best Medical Treatment Plus Renal Artery Stenting (RADAR)

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Keywords

renovascular hypertension, renal artery stenosis, renin-angiotensin-aldosterone, renin-angiotensin-aldosterone system, renin, angiotensin, aldosterone, renin angiotensin, fibromuscular dysplasia, renovascular occlusive disease, atherosclerotic renal artery disease, atherosclerotic renovascular disease, renal artery occlusive disease, RVHT, renal artery occlusion, renal arterial vascular disease, hyperreninemia, arterial occlusive disease, renal ischemia, angiotensin I, angiotensin II, secondary hypertension

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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.

Medical Editor

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

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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.

CME Editor

Michael E Zevitz, MD, Assistant Professor of Medicine, Finch University of the Health Sciences, The Chicago Medical School; Consulting Staff, Private Practice
Michael E Zevitz, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Medical Association, and Michigan State Medical Society
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.

 
 
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