• Caused most often by renal artery stenosis (RAS)
• Rare causes of renovascular hypertension
• Juxtaglomerular complex secrete increased renin resulting in increased angiotensin II, aldosterone levels; leads to chronic changes in kidneys
• Stenosis at orifice of main renal artery
• Usually starts in aorta extends into renal artery, rarely originates in renal artery
• Most asymptomatic
• Irritability, headache, depression
• Persistent elevation of diastolic blood pressure
• Bruit frequently present in abdomen
• Consider this diagnoses for early-onset hypertension, antihypertensive drug resistance, deterioration of renal function, diastolic blood pressure > 115 mm Hg, deterioration of renal function with ACE inhibitors
• Selective renal vein blood renin levels
• RVRR not accurate if bilateral RAS
• Captopril stimulation test causes drop in blood pressure in renin-dependent hypertension
• Captopril renal scintigraphy: Preferred study to establish diagnosis
• Duplex US
• Magnetic resonance angiography (MRA) with gadolinium avoids nephrotoxicity, overestimates stenosis
• IVP, duplex may be used for screening
• Arteriogram or MRA should be performed prior to any surgical intervention
• Endarterectomy: If lesion focal and close to aorta
• Arterial replacement
• Splenorenal, iliorenal, hepatorenal bypasses are nonanatomic bypasses with good results
• Nephrectomy should be considered if unilateral and atrophic kidney
• Percutaneous angioplasty/stent best for focal lesions distant from aorta; patients with fibromuscular dystrophy preferred
• Extent of disease in renal arteries
• Poor response to medical therapy
• Associated arterial disease
• Patient's life expectancy
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