How Important Is Atheromatous Renal Artery Stenosis as a Cause of End‐Stage Renal Disease?

Abstract

In recent years atheromatous renal artery stenosis has been proposed as a common and potentially preventable cause of end-stage renal disease (ESRD). Occlusive renal artery disease causes renal failure that can be reversed following successful revascularization, but this scenario is relatively rare. Nonocclusive renal artery stenosis is commonly found in association with varying degrees of renal impairment. However, recent evidence and clinical observation suggest that a cause and effect relationship is unlikely. Experimentally, split renal function studies in cases of unilateral stenosis find similar degrees of renal impairment in both kidneys. Clinically, severe renal impairment is often found in the presence of unilateral stenoses. Another nephropathic process must be going on, probably a combination of hypertensive and atheroembolic damage. It is not surprising that the two pathologies often coexist, in view of their shared causes (principally hypertension and tobacco smoking). Previous studies of the importance of renal artery stenosis in causing ESRD probably included many cases of hypertensive and atheroembolic nephropathy. Unfortunately the potential for renal revascularization to prevent ESRD has been exaggerated.

TGF Expression and Macrophage Accumulation in Atherosclerotic Renal Artery Stenosis

“…When endovascular or surgical repair is achieved early after loss of renal perfusion or in kidneys for which some collateral blood flow has been preserved (38), salvage of renal function sometimes can be accomplished. However, most patients have little return of GFR, and some lose function further, leading some authors to argue that renal revascularization has little meaningful benefit (39). Our results suggest that part of the underlying renal injury represents a transition to inflammatory and fibrotic injury that does not resolve with restoring renal blood flow alone.…”

Smoking and the Kidney

“…This assumption is based on the consideration that apart from luminal narrowing of the renal artery, a combination of arteriolar and atheroembolic damage (i.e., cholesterol microembolism) is thought to contribute to progressive loss of renal function. Actually, smoking is a known risk factor for cholesterol microembolism (64).…”

Renal Artery Stenosis: A Unique Disease or a Broad Spectrum of Different Diseases?

“…On the one hand, the advocates of an aggressive approach [31,32] underline the likely prospect of recovering renal function in many patients and the chance of preventing a likely progression towards chronic renal failure. On the other, the supporters of the wait-and-see approach [33][34][35] raise the objection that no randomised trial has ever demonstrated the superiority of revascularization over medical treatment in regard to blood pressure control and renal function recovery. They also stress the fact that the revascularization manoeuvres are weighed down by frequent complications.…”