Renovascular Hypertension Treatment & Management

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

Medical Care

  • Antihypertensive drug therapy is indicated.
  • Optimal blood pressure control plays an essential role in the therapeutic management of RVHT; however, aggressive control of other risk factors for atherosclerosis also is key.
  • Cessation of smoking is important for its positive impact on the cardiovascular risk profile in patients with hypertension. Similarly, antidyslipidemic therapy for those patients with hyperlipidemia likely provides benefit in atherosclerotic RVHT.
  • Progression of atherosclerotic stenosis may occur in as many as one third of patients, and the sequelae of ongoing ischemia to the stenotic kidney are a theoretical concern. Furthermore, normalization of blood pressure may be associated with reduced renal perfusion pressures, and renal function may deteriorate despite good blood pressure control.
  • Definitive therapy for the underlying cause must be considered in order to avoid the development of ischemic nephropathy. Intervention of hemodynamically significant stenoses has been presumed to offer clinical benefit; however, trials comparing renal artery revascularization with medical management do not unequivocally favor surgical over medical intervention.[3] Thus, the superiority of surgical intervention versus medical intervention (or vice versa) remains unproven.
  • Percutaneous transluminal renal angioplasty
    • Percutaneous transluminal angioplasty (PTRA) is a nonsurgical procedure used to open stenotic renal arteries, the most amenable lesions being those without total occlusion. Outcomes in patients with lesions resulting from fibromuscular dysplasia appear to be significantly better than they are in persons whose lesions are associated with atherosclerotic stenosis, with cure reported in 50-85% of patients in the former group, and in 8-20% of persons in the latter group.
    • Restenosis requiring repeat angioplasty was reported in fewer than 10% of patients with fibromuscular disease and in 8-30% of those with atherosclerotic stenosis. Improvement in blood pressure control with fewer antihypertensive medications was achieved in 30-35% and 50-60% of patients with fibromuscular or atherosclerotic lesions, respectively.
    • A Swedish study of 105 patients treated with PTRA reported a 5-year survival rate of 83% for patients with arteriosclerotic renovascular disease.[4] The rate for patients with fibromuscular vascular disease was even higher, reaching 100%.
    • The poor results observed in patients with bilateral renal artery disease suggest that surgical intervention should be a strong consideration in this setting.
    • Intravascular stents placed during angioplasty (see the images below) may be helpful in the prevention of restenosis and the management of RVHT. Current data suggest that stenting may prove useful in patients with ostial disease, those who develop restenosis after PTRA, or those with complications resulting from PTRA, such as dissection. Primary renal artery stenting in patients with atherosclerotic RAS has a high technical success rate and a low complication rate.[5, 6]
    • In patients with diffuse atherosclerosis, the complication rate with either surgery or angioplasty is relatively high. Medical therapy may be preferred. Angiogram showing bilateral renal artery stenosis.Angiogram showing bilateral renal artery stenosis. Courtesy of Department of Radiology, Henry Ford Hospital. After percutaneous transluminal angioplasty (rightAfter percutaneous transluminal angioplasty (right renal artery). Courtesy of Department of Radiology, Henry Ford Hospital. After percutaneous transluminal angioplasty and stAfter percutaneous transluminal angioplasty and stent placement (left renal artery). Courtesy of Department of Radiology, Henry Ford Hospital.
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Surgical Care

  • Surgical revascularization
    • The underlying diagnosis is the major determinant of the results of this surgery. As more patients with advanced atherosclerosis in multiple vessels are brought to surgery, performing various bypass procedures may become less feasible because of the following: (1) the certainty that the RAS is the cause of the hypertension is less, and (2) the prognosis may be determined by the extent of atherosclerosis elsewhere in the body.
    • Another potential problem is the release of cholesterol emboli during the operation; however, 80-90% of patients undergoing operation for atherosclerotic RVHT benefit (cure or improvement), with a perioperative mortality rate of less than 5%.
    • In patients with fibromuscular dysplasia, the cure rate is as high as 80% and morbidity is low; however, these results are not significantly better than what can be achieved with renal angioplasty, at less morbidity, mortality, cost, and inconvenience.
  • In patients with diffuse atherosclerosis, the complication rate with both surgery and angioplasty is relatively high.
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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.

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.

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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.
 
 
 
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