Патогенез сдавление почечных артерий → decreased renal perfusion of one or both kidneys → ↑ renin release → ↑ angiotensin:
causes generalized arteriolar constriction
↑ aldosterone → ↑ Na+ and water retention
elevated blood pressure → to further damage of kidneys and worsening HTN
Signs and Symptoms
severe/refractory HTN and/or hypertensive crises, with negative family history of HTN
asymmetric renal size
epigastric or flank bruits
spontaneous hypokalemia (renin activation in under-perfused kidney)
increasing Cr with ACEI/ARB
flash pulmonary edema with normal LV function
Investigations
must establish presence of renal artery stenosis and prove it is responsible for renal dysfunction
duplex Doppler U/S (kidney size, blood flow): good screening test (operator dependent)
digital subtraction angiography (risk of contrast nephropathy)
CT or MR angiography (effective noninvasive tests to establish presence of stenosis, for MR avoid gadolinium contrast if eGFR <30 mL/min because of risk of systemic dermal brosis)
ACEI renography (i.e. captopril renal scan)
renal arteriography (gold standard)
Treatment
surgical: percutaneous angioplasty ± stent, surgical revascularization, occasionally surgical bypass
medical: BP lowering medications (ACEI is drug of choice if unilateral renal artery disease but contraindicated if bilateral renal artery disease)
little or no bene t if therapy is late i.e. kidney is already shrunken (however, therapy can be considered to save the opposite kidney if normal)