Atherosclerotic Renovascular Disease: A KDIGO (Kidney Disease: Improving Global Outcomes) Controversies Conference

Abstract

The diagnosis and management of atherosclerotic renovascular disease (ARVD) is complex and controversial. Despite evidence from the ASTRAL (2009) and CORAL (2013) randomized controlled trials showing that percutaneous renal artery revascularization did not improve major outcomes compared with best medical therapy alone over 3-5 years, several areas of uncertainty remain. Medical therapy, including statin and antihypertensive medications, has evolved in recent years, and the use of renin-angiotensin-aldosterone system blockers is now considered the primary means to treat hypertension in the setting of ARVD. However, the criteria to identify kidneys with renal artery stenosis that have potentially salvageable function are evolving. There are also data suggesting that certain high-risk populations with specific clinical manifestations may benefit from revascularization. Here, we provide an overview of the epidemiology, diagnosis, and treatment of ARVD based on consensus recommendations from a panel of physician experts who attended the recent KDIGO (Kidney Disease: Improving Global Outcomes) Controversies Conference on central and peripheral arterial diseases in chronic kidney disease. Most focus is provided for contentious issues, and we also outline aspects of investigation and management of ARVD that require further research.

Keywords: Atherosclerotic renovascular disease (ARVD); RAAS blockade; blood pressure control; chronic kidney disease (CKD); fibromuscular dysplasia (FMD); heart failure (HF); ischemic nephropathy; renal artery stenosis (RAS); renin-angiotensin-aldosterone system (RAAS); revascularization; treatment recommendations.

Figure 1.

Major pathways leading to kidney injury beyond “critical” levels of renal artery stenosis. Left column depicts sequence of microvascular injury resulting from loss of perfusion. Histologic sections (A and B) identify reduced glomerular volume and areas without intact tubules but with increased mononuclear inflammatory cells, consistent with irreversible kidney injury. Blood oxygen level–dependent magnetic resonance (BOLD-MRI) images (C and D) depict levels of tissue oxygenation with moderate reductions (30%-40%) of renal blood flow. Legend on right indicates the level of deoxyhemoglobin, which identifies the level of local tissue hypoxia. In C, cortical levels of deoxyhemoglobin are normally low, consistent with abundant tissue oxygenation even with reduced blood flow. As more severe and sustained reductions develop, areas of severe localized hypoxia are evident, with increased tissue deoxyhemoglobin (D).

Figure 2.

Examples of atherosclerotic renovascular disease imaged using multidetector computed tomographic angiography (CTA; A), magnetic resonance angiography (MRA; B), and catheter angiography using carbon dioxide (C) or iodinated contrast medium.