Abstract: FR-PO014

Managing Bilateral Renal Artery Stenosis (RAS)

Session Information

Category: Nephrology Education

  • 1302 Fellows and Residents Case Reports

Authors

  • Lam, Franklin, None, Providence, Rhode Island, United States
  • Chaudhry, Rafia I., None, Providence, Rhode Island, United States
  • Salman, Loay H., Albany Medical College, Albany, New York, United States
  • Monrroy, Mauricio, None, Providence, Rhode Island, United States
Background

Renal artery stenosis (RAS) accounts for 2-4% cases of HTN in the US. Etiology of RAS includes age related atherosclerosis, and fibromuscular dysplasia in young females.

Methods

79-year-old Caucasian female, with PMHx of well controlled HTN, HLD, DM 2 and CKD (baseline Cr 1.7 mg/dL) presented with HTNsive urgency (BP 220/90 mm Hg), AKI (Cr 2 mg/dL), pulmonary edema and severe LE edema. Cr notably worsened over 6 months. Abdominal CTA revealed severe bilateral RAS. Renal artery stenting was held due to AKI with Cr rising to 3 mg/dL. After prolonged hospitalization, pt was discharged on medical therapy (Bumetanide, Doxazosin, Clonidine, Metoprolol, and Nifedipine). Cr remained elevated at 3.1 mg/dL on follow-up. Pt underwent left renal artery stenting at this time. Right renal artery was not amenable to stenting due to complete occlusion. Renal function improved, Cr stabilized at 1.4 mg/dL at five months later. BP and volume status well controlled.

Conclusion

RAS results in decreased renal perfusion and activation of renin-angiotensin-aldosterone system (RAAS), resulting in systemic vasoconstriction, Na retention and HTN. Significant reduction of renal blood flow occurs at greater than 70% narrowing of the artery. As the stenosis worsens global renal ischemia leads to shrinking of the affected kidney, and AKI or CKD. While medical therapy is initially indicated, failure of medical therapy i.e. worsening renal function, poorly-controlled BP, recurrent pulmonary edema and hypervolemia are indications for revascularization that is performed with percutaneous transluminal renal angioplasty (PRTA). Despite multiple studies showing the effectiveness of medical therapy, there is still a role for targeted endovascular therapy in cases of RAS resistant to conventional therapy.