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00004872-200111000-0002600004872_2001_19_2109_alcazar_renovascular_11miscellaneous< 68_0_7_0 >Journal of Hypertension© 2001 Lippincott Williams & Wilkins, Inc.Volume 19(11)November 2001pp 2109-2111How to handle renovascular hypertension [European Society of Hypertension Scientific Newsletter: Update on Hypertension Management]Alcazar, Jose M.; Rodicio, Jose L.Introduction.Renovascular hypertension (RVH) is defined as the elevation of arterial pressure precipitated by a hemodynamically significant stenosis of a renal artery or arteries (that is, stenosis caliber greater than 75% of the vessel lumen or than 50% with post-stenotic dilation). When the lesion affects both renal arteries or a single functioning kidney and is accompanied by renal failure (plasma creatinine concentration above 1.5 mg/dl), it is called ischemic nephropathy [1,2].The rate of renovascular hypertension (RVH) is less than 1% when a mild-moderate hypertension population is assessed but this increases according to the severity of the hypertension and population age [3]. In 4,429 patients with arterial hypertension, Anderson et al. [4] found a prevalence of 3.1%, (2.7% attributed to atherosclerosis and 0.4% to fibro-muscular dysplasia).Screening test. Signs and symptoms which point to RVH are: sudden onset of hypertension, especially in young ages subjects a particularly in women (due to fibrodysplastic lesion); the existence of severe hypertension in males over 60 years, with signs of atherosclerosis in other vascular territories [5–7]; hypertension and abdominal bruit; grade III retinopathy in 25%–40% of the patients [8], elevation of serum creatinine after the administration of angiotensin converting enzyme (ACE) inhibitor [9–10]; episodes of cardiac failure and acute pulmonary edema [11]; hypertension refractory to treatment with > 3 antihypertensive drugs. In all of these patients, the existence of RVH should be suspected. Although the renal arteriography is the ‘‘gold standard’’ for the diagnosis of RVH, it is an invasive method with possible complications so several non-invasive procedures can be used for the first diagnostic approximation. Those procedures which are used the most are the: *  Renal scintigraphy following ACE inhibitor: Its sensitivity and specificity is 78%–90% and 88%–95% respectively [12–14], which decreases when there is bilateral lesion and renal insufficiency. *  Duplex Doppler ultrasonography: Its sensitivity ranges from 92% to 98%[15,16] and the most significant limitation of this ultrasonography is found in the localization of the renal arteries. This depends on the degree of abdominal obesity, the intestinal gas content, on the experience and patience of the observer and on the time spent carrying out the examination. *  Magnetic resonance angiography: Its sensitivity and specificity ranges from 83% to 100% and from 92% to 97% respectively for these studies when the stenosis is greater than 50% of the renal artery caliber [17,18]. *  Spiral CT angiography: The sensitivity of this method is 67% to 92%[19,20]; however, this can be improved to 98% with a specificity of 84% when maximum intensity projections and three dimensional techniques are used. *  Renal vein renin measurements: Although 90% of the patients with RVH and lateralization of renin values have a positive response to revascularization (angioplasty or surgery), 50% of the RVH that do not show lateralization also benefit from the correction of the stenosis [21]. At present, this test is rarely used, except for the assessment of patients with lesions in both renal arteries, in order to determine which kidney has the more significant contribution to the maintenance of the hypertension.In our experience, when there is high clinical suspicion of RVH, renal arteriography is used directly to both verify the lesion and also perform an angioplasty when the lesion is due to fibrodysplasia, is hemodynamically significant and has a significant gradient.When there is only moderate clinical suspicion, any of the above mentioned examinations (renal scintigraphy, duplex Doppler, magnetic resonance and spiral CT angiography) may be carried out dependent on the results and experience of each hospital. A negative test excludes RVH but and if positive, a renal arteriography should be performed.Treatment.The fundamental objective of RVH treatment is to preserve or maintain renal function in addition to controlling blood pressure. Pharmacological treatment alone with ACEI, either alone or plus a diuretic, successfully normalizes the blood pressure values in 90% of the cases but does not prevent the progression of the vascular lesions of the renal artery which occurs in 45% to 60% of the patients with atherosclerotic vascular disease over the next 4 to 7 years. Complete thrombosis of the arterial lumen develops in 10%–15% of the cases when the stenosis caliber is greater than 75% of the vessel lumen [5].In a prospective study on 170 patients with RVH (295 arteries) and an atherosclerotic etiology treated with antihypertensive drugs and controlled by the duplex Doppler technique, Caps et al. [22] demonstrated a cumulative progression of the vascular lesions at three years of 28% when the initial stenosis was less than 60% of the vessel lumen; 49% progressed when the initial caliber was greater than 60%. Complete occlusion of the vascular lumen occurred in 3% of the arteries in this group. In fibromuscular dysplasia, progression and complete thrombosis can occur on rare occasions.With demonstrated renal artery stenosis hemodynamically significant, basis of treatment will be revascularization by angioplasty and/or surgery depending on the etiology of the lesion and its location in the renal artery.Percutaneous transluminal renal angioplasty (PTRA): In a meta-analysis performed with a total of 691 patients from 10 centers, Ramsey and Waller [23] found that when this technique was used, in subjects with fibromuscular dysplasia 50% of the patients were cured, 42% improved and 8% failed; in those patients with atherosclerosis, the results were worse: 19%, 51% and 30% respectively. A residual stenosis more than 50% was observed in 12%: 15% in the atherosclerotic patients and 9% in those with fibromuscular dysplasia. In 595 patients with PTRAs performed with the coaxial technique, Klow et al. [24] found that the failure rate was 8%, and that this failure always occurred in patients with atherosclerosis.Moss et al. [25] performed a meta-analysis on 14 studies with a total of 512 patients and found a total of 22.9% complications, particularly 5% transitory increase of the serum creatinine, 1.6% renal hematoma, 1.6% dissection and rupture of the renal artery and 2% renal atheroembolism.Restenosis in the first 12 months is frequent (12%) [26,27] due to recoil phenomenon and neointimal proliferation.Intravascular stents:The fundamental indication for these stents is when there are ostial lesions having of atherosclerotic etiology which are not susceptible to surgery. They are difficult to assess as, in some cases, the stents are placed after failure or restenosis of the initial angioplasty. The cure or improvement criteria increase to 65% -78%, with less severe stenosis.In a randomized study at 6 months in 85 patients with ostial atherosclerotic renal artery stenosis, van de Ven [28] found that the results of treatment with PTRA plus stent are better (77% versus 29%) than with PTRA alone and the restenosis (77% versus 29%) than with PTRA alone and the restenosis incidence is lower (14% versus 48%).Surgery:Surgical revascularization is more effective than PTRA in the treatment of atherosclerotic disease, with cure or improvement of the hypertension in 85% to 90% of the cases [3,29,30], although in the large majority of the cases, the indication is based on protecting or improving renal function. Aortorenal bypass is the most commonly used technique, but hepatorenal and splenorenal bypass are frequently used which avoids operations on the aorta. In the case of bilateral lesions, there are multiple indications and solutions, such as unilateral bypass with contralateral angioplasty and contralateral nephrectomy in cases of atrophic kidneys. In some cases of ischemic nephropathy with complete obstruction of the renal artery (non-functioning kidneys), significant improvement of renal function can be obtained, provided series of conditions are fulfilled [29,30] and a bypass is technically possible [31].The surgical mortality ranges from 2%–6% and is related to the age of the patient, the degree of atherosclerosis (coronary or cerebrovascular disease) and renal function [29,30].Summary.Given the low prevalence of RVH, investigation should be based on the clinical history. When there is very high clinical suspicion, renal arteriography can be used as the first examination. In cases of moderate or low suspicion, a non-invasive test, chosen according to the experience of each center, can be used as a first approach; if this is positive, a confirmatory arteriography should be done.The technique of choice for patients with fibromuscular dysplasia is PTRA because its excellent results, low morbidity and low relapse rate. In atherosclerotic disease, surgical revascularization is the first indication. In the cases of bilateral renovascular disease and renal insufficiency, global assessment of the patient is necessary with the risks and benefits must be considered, according to the experience of each hospital.References1. Jacobson HR. Ischemic reanl disease: an overlooked clinical entity? Kidney Int 1988; 34: 729–743. [CrossRef] [Medline Link] [Context Link]2. Breyer JA, Jacobson HR. Ischemic Nephropathy. Curr Opin Nephrol Hyperten 1993; 2: 216–224. [Context Link]3. Working Group on Renovascular Hypertension. Detection, evaluation and treatment of renovascular hypertension. Final report. Arch Intern Med 1987; 147: 820–829. [Context Link]4. Anderson GH, Blakeman M, Streeten DHP. The effects of age on prevalence of secondary forms of hypertension in 4429 consecutively referred patients. J Hypertens 1994; 12: 609–615. [Context Link]5. Greco BA, Breyer JA. Athersclerotic ischemic renal disease. Am J Kidney Dis 1997; 29: 167–187. [Context Link]6. Alcazar JM, Caramelo C, Alegre E, Abad J. Ischaemic renal injury. Curr Opin Nephrol Hyperten 1997; 6: 157–165. [Context Link]7. Alcarza JM, Rodicio JL. Ischemic nephropaty: clinical charatcteristics and treatment. Am J Kidney Disease 2000; 36: 883–893. [Context Link]8. Davis BA, Crook JE, Vestal RE, Oakes JA. Prevalence of renovascular hypertension in patients with grade III or IV retinopathy. N Engl J Med 1979; 301: 1273–1276. [CrossRef] [Medline Link] [Context Link]9. van de Ven PJ, Beutler JJ, Kaatee R, Frederik JA, Beek FJA, Mali WP, Koomans HA. 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