Abstract: SA-PO0370
Renal Artery Stents: Never Say Never
Session Information
- AKI: Case Reports - Drug/Toxin Injury, Crystals, Obstruction, and Unusual Presentations
October 24, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Acute Kidney Injury
- 102 AKI: Clinical, Outcomes, and Trials
Authors
- Quiñones-Cruz, Katherine M., The University of Chicago, Chicago, Illinois, United States
- McGill, Rita L., The University of Chicago, Chicago, Illinois, United States
- Rafey, Mohammed A., The University of Chicago, Chicago, Illinois, United States
Introduction
Atherosclerotic renal artery stenosis (ARAS) affects approximately 6.8% of adults > 65 years; 21% of cases are bilateral. The ASTRAL & CORAL trials showed no benefit of stenting over medical therapy in stable ARAS but excluded patients with flash pulmonary edema and dialysis-dependent AKI (AKI-D), populations most likely to benefit. We report a patient with AKI-D and progressive ARAS in a solitary functioning kidney (SFK) with durable recovery after revascularization.
Case Description
An 88-year-old woman with CKD G4/A1 presented with HTN urgency and pulmonary edema despite preserved ejection fraction. Duplex ultrasound six months earlier demonstrated right ARAS with ostial peak systolic velocity (PSV) 416 cm/s, renal:aortic ratio 5.2, and high resistive indices (RI) in both cortex (0.75) and medulla (0.83). Kidney length was 10.4 cm. The left kidney was 3.1 cm with absent doppler flow.
Despite IV diuretics her creatinine (Scr) rose from 2.67 to 3.53 mg/dL. HTN was refractory to five agents, and repeat duplex demonstrated right RI worsening from 0.83 to 1.00 and PSV from 416 to 494 cm/s. She developed AKI-D with Scr 5.89mg/dL, with pulmonary edema and hyperkalemia – the key findings of Pickering Syndrome. A right renal artery angioplasty via left radial access reduced the ostial stenosis from 90% to 20%.
After one more dialysis, her urine output recovered and Scr improved to 2.7 mg/dL. She is dialysis-free with Scr 2.4 mg/dL, 18 months later.
Discussion
This case highlights two key points. First, progressive ARAS of a SFK was the mechanism of decompensation, given atrophy of the left kidney. Worsening ARAS eliminated residual renal reserve, precipitating crisis. SFK is a setting in which renal salvage after revascularization has been reported, and the 2022 AHA guidelines list this as a setting in which revascularization may be considered. Second, meaningful recovery occurred despite RI=1.00. Although RI > 0.80 often predicts poor outcomes after revascularization, in this case, the preserved kidney size and the acute decompensation suggested a potential reversibility superimposed on chronic disease. In a meta-analysis, renal artery stenting improved/stabilized renal function in 82/253 SFK patients. Kidney size > 9 cm was a key predictor of clinical benefit. Our patient’s durable response supports individualized consideration of revascularization in carefully selected patients, even those with unfavorable RI.