History and Physical

Patients with ischemic renal vascular disease (RVD) present with one or more of the following clinical, historical, or diagnostic scenarios.

Because of the strong association of RVD with generalized atherosclerosis, many patients with RVD will have evidence of cerebrovascular, cardiovascular, or peripheral vascular disease (eg, carotid bruits, history of transient ischemic attack or stroke). Abdominal bruits are highly specific for RVD when heard over the flank and are back-and-forth in nature (ie, present during both systole and diastole).

Sudden worsening of hypertension or kidney function may occur. Acute kidney injury or decreased kidney function may occur after initiation of antihypertensive therapy, especially with angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs); an increase in serum creatinine levels of more than 15% in this setting is strongly suggestive of RVD.

Unexplained kidney insufficiency may develop in elderly patients.

Congestive heart failure may occur with poor control of hypertension and renal insufficiency in the absence of a significant decrease in ejection fraction (so-called flash pulmonary edema). Although flash pulmonary edema has been reported in patients with unilateral renal stenosis, it occurs more commonly in patients with bilateral renal stenosis.^[6]

Differential Diagnoses

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Media Gallery

Renal artery stenosis/renovascular hypertension. Left, Sonograms of the kidneys on a 57-year-old woman with difficult-to-control hypertension shows kidneys of uneven sizes: The left kidney is 96 mm, and the right kidney is 63 mm. Top right, Isotopic renogram (obtained with technetium mercaptoacetyltriglycine [MAG3]) after captopril shows a markedly depressed renal function in the right kidney. Bottom right, Analogous images show negligible activity in the right kidney. Note that this pattern is more typical for DTPA than MAG3 (as DTPA depends on the glomerular filtration rate for uptake which is decreased after captopril in renovascular hypertension [RVHT]). In severe cases of RVHT, MAG3 uptake can be decreased, as in this case. However, typically, uptake is preserved with decreased cortical excretion.
Renal artery stenosis/renovascular hypertension. Left, Flush aortogram in a 63-year-old man with hypertension shows marked stenosis of the right renal artery and complete occlusion of the left renal artery. Note the extensive atheroma in the aorta and iliac arteries. Right, nephrogram-phase image shows a significantly smaller left kidney with a faint nephrogram. Some blood supply to the left kidney is retained via collaterals (see image on the left).
Renal artery stenosis/renovascular hypertension. Flush aortogram in a 32-year-old man with familial hypercholesterolemia and difficult-to-control hypertension. Radiograph shows a complete occlusion of the right renal artery and marked stenosis of the left renal artery (arrow).
Three-dimensional gadolinium-enhanced magnetic resonance angiograms (MRAs) show medial fibroplasia, which appears as classic string-of-beads sign. This sign is due to multiple stenoses with intervening outpouchings that form a chain. In this case, the lesions involve the main right renal artery and the right accessory renal artery in a 37-year-old man with difficult-to-control hypertension.
Conventional flush aortogram in a 47-year-old woman with difficult-to-control hypertension shows the characteristic string-of-beads sign (arrows) of the right renal artery due to medial fibroplasia.

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Author

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.

Coauthor(s)

Joanna M Rodriguez, MD Nephrologist, Memorial Healthcare System

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, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: American Society of Nephrology<br/>Received income in an amount equal to or greater than $250 from: Healthcare Quality Strategies, Inc.

Chief Editor

Vecihi Batuman, MD, FASN Professor of Medicine, Section of Nephrology-Hypertension, Deming Department of Medicine, Tulane University School of Medicine

Vecihi Batuman, MD, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Acknowledgements

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

Disclosure: Nothing to disclose.