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Renovascular hypertension

Renovascular hypertension (or "renal hypertension") is a syndrome which consists of high blood pressure caused by narrowing of the arteries supplying the kidneys (renal artery stenosis). It is a form of secondary hypertension - a form of hypertension whose cause is identifiable.

Diagnosis and presentation

Techniques have been developed to diagnose renal hypertension using digital image processing of radiographs. Treatment may involve angioplasty and stenting of the renal arteries. The syndrome may be related to other diseases of the epithelium.

Suggestive clinical features include onset of hypertension <30 or >50 years of age, abdominal or femoral bruits, hypokalemic alkalosis, moderate to severe retinopathy, acute onset of hypertension or malignant hypertension, and hypertension resistant to medical therapy.

The "gold standard" in diagnosis of renal artery stenosis is conventional arteriography. Magnetic resonance angiography (MRA) is used in many centers, especially among pts with renal insufficiency at higher risk for contrast nephropathy. MRA may overestimate the severity of stenosis relative to angiography. In pts with normal renal function and hypertension, the captopril (or enalaprilat) renogram may be used. Lateralization of renal function [accentuation of the difference between affected and unaffected (or "less affected") sides] is suggestive of significant vascular disease. Test results may be falsely negative in the presence of bilateral disease.

Treatment

Renal hypoperfusion activates renin-angiotensin-aldosterone (RAA) axis; ACE inhibitors and ARB classes of antihypertensives are contraindicated as they might compromise the renal function especially if the Stenosis is bilateral. Nitroprusside, labetalol, or calcium antagonists are generally effective in lowering bp acutely, although inhibitors of the RAA axis [e.g., ACE inhibitors, angiotensin II receptor blockers (ARBs)] are most effective long-term treatment, if disease is not bilateral.

Surgical revascularization appears to be superior for ostial lesions characteristic of atherosclerosis. The relative efficacy of surgery compared with angioplasty (especially with stenting) for fibromuscular dysplasia or for nonocclusive, nonostial atherosclerotic disease is unclear. Angioplasty (with or without stenting) tends to be most effective for mid-vessel or more distal lesions. No studies have adequately compared revascularization with medical therapy. ACE inhibitors or ARBs are ideal agents for hypertension associated with renal artery stenosis, except in pts with bilateral disease (see "Ischemic Nephropathy," below) or disease in a solitary kidney (including an allograft).