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MEDICAL GRAND ROUNDS WILLIAM S. WILKE, MD, EDITOR
POINTS FROM
LECTURES BY
CLEVELAND CLINIC
A N D VISITING
FACULTY
Screening for renal artery stenosis:
Which patients? Which test?
D O N A L D G. VIDT, M D all new hypertensive patients for renal artery
Consultant, Department of Nephrology and Hypertension, Cleveland Clinic;
member, National High Blood Pressure Education Program Working Group
stenosis. Screening is more cost-effective and
on Chronic Renal Failure and Renovascular Hypertension should have a greater predictive value in
patients with one or more clues suggestive of
• ABSTRACT renal artery stenosis.
The clinical evaluation should therefore
If a patient has clinical clues suggestive
begin with a carelul medical history and thor-
of renovascular hypertension such as
ough physical examination that can uncover
persistently high blood pressure despite
important clinical clues suggesting renovascu-
a multiple-drug regimen, it may be lar hypertension, such as:
reasonable to screen him or her using Abrupt onset of hypertension before age
captopril renography, duplex 30 or after age 55
ultrasonography, or magnetic resonance Accelerated or malignant hypertension
angiography. (with grade 3 or 4 retinopathy)
Hypertension refractory to an appropriate
F A PATIENT has persistently high blood triple-drug regimen
Screening is pressure despite multiple medications, Moderate hypertension in a patient with
t h e problem may be renovascular hyperten- diffuse atherosclerosis (eg, in the carotid,
reasonable in sion: high blood pressure induced by a critical coronary, and peripheral arteries)
patients with decrease in perfusion to o n e or b o t h kidneys, A continuous systolic-diastolic epigastric
usually due t o renal artery stenosis, and associ- bruit
clinical clues ated with a c t i v a t i o n o f t h e r e n i n - a n g i o t e n s i n - Moderate hypertension and unexplained
suggesting aldosterone system. azotemia
Renovascular hypertension probably Azotemia induced by an angiotensin-con-
renal artery
accounts for only about 1% of cases of high verting enzyme inhibitor or angiotensin
stenosis blood pressure, but it accounts for as many as receptor blocker
3 0 % of patients seen in hypertension referral A unilateral small kidney by any prior
centers because of refractory hypertension. 1 investigational procedure
Atherosclerosis accounts for approxi- Undiagnosed renal insufficiency, with or
mately 7 0 % of cases of renal artery stenosis, without hypertension (particularly with
and is especially common in older patients. 2 normal urine sediment)
In this age group, extensive atherosclerosis of "Flash pulmonary edema" (ie, of sudden
the abdominal aorta and proximal renal arter- onset) in the presence of hypertension and
ies often leads to ischemic nephropathy. On diffuse atherosclerotic vascular disease.
the other hand, fibromuscular dysplasia
accounts for more cases in younger patients. W H A T IS THE FIRST, BEST TEST TO USE?
• W H O SHOULD BE SCREENED? If a patient has normal renal function and
clinical clues suggestive of renal artery steno-
In view of the low prevalence of renovascular sis, I would recommend any of three screening
hypertension, it is not cost-effective to screen tests:
3 1 8 C L E V E L A N D C L I N I C J O U R N A L OF M E D I C I N E V O L U M E 67 • N U M B E R 5 MAY 2000
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• Captopril renography, patients with impaired renal function. Ideally
• Duplex ultrasonography, or other antihypertensive agents should be dis-
• Magnetic resonance angiography. continued several days before testing.
In older patients or those with impaired Recent advances in treatment have stim-
renal function, I prefer duplex ultrasonogra- ulated interest in developing improved nonin-
phy because it provides some anatomic imag- vasive screening tests for renovascular hyper-
ing of the renal artery, retains its sensitivity tension.3.4
despite impaired renal function, and in most
institutions is a bit more cost-effective than Captopril renography
magnetic resonance angiography. If this test is Captopril renography consists of renal
not available, however, magnetic resonance scintigraphy using any one of several appro-
angiography with gadolinium is also useful for priate isotopes, performed at baseline and
screening for renal artery stenosis. again 30 to 60 minutes after ingestion of 25
For the occasional patient in whom these or 50 mg of captopril. A reduced uptake of
noninvasive screening tests are nondiagnostic the radionuclide and prolonged time to max-
and the suspicion for renal artery stenosis imal activity after captopril administration
remains high, intra-arterial digital subtraction indicate delayed excretion and possibly renal
angiography may be considered. This proce- artery stenosis.
dure provides images of comparable quality to Advantages. Captopril renography can
those of standard arteriography and uses less identify critical renal artery stenosis with a
contrast medium, entailing a lower risk of con- sensitivity and specificity exceeding 90%. 3
trast nephrotoxicity in patients with renal Disadvantages. Captopril renography
insufficiency. O n the other hand, it is invasive does not provide information about renal
(entailing aortic catheterization) and carries artery anatomy. In addition, its sensitivity and
risks similar to those observed with standard specificity may be reduced in patients with
arteriography. renal insufficiency. This limitation can pose a
problem in older patients being screened for
• A D V A N T A G E S A N D DISADVANTAGES possible ischemic nephropathy. Duplex
OF THE DIFFERENT TESTS
Duplex ultrasonography
ultrasound may
Intravenous pyelography and renography Duplex ultrasonography combines direct (B- be best in older
using iodine-131 orthoiodohippurate are no mode) imaging with Doppler measurement of
longer used because of poor sensitivity and the velocity of blood flow. Results are usually
patients and
specificity. Intravenous pyelography may also given as one of three degrees of stenosis: 6 0 % those with
carry an increased risk of contrast-induced or less, 6 0 % to 99%, or total occlusion.
nephrotoxicity in older patients with suspect-
renal failure
Advantages. Duplex ultrasonography pro-
ed ischemic nephropathy. Measurement of vides both an anatomic and functional assess-
plasma renin activity also has poor sensitivity ment of the degree of stenosis and a measure-
and specificity and is highly subject to the ment of the kidneys' size. Sensitivities exceed-
influence of other drugs that may induce spu- ing 9 0 % and specificities approaching 100%
rious values. These older screening tests have are reported.5 The results correlate well with
also failed to accurately predict the blood pres- those of renal angiography. Duplex scanning is
sure response to revascularization. noninvasive, requires no contrast material,
The captopril plasma renin test (measure- and is therefore safe in patients with impaired
ment of plasma renin activity after a single renal function. It has also proved useful for
dose of captopril) is relatively inexpensive and serial follow-up after intervention.
can be performed on an outpatient basis. Its Continuing technologic developments will
major limitation is that it does not provide any facilitate determinations of flow velocities and
information about the anatomy of the renal pressure gradients across stenoses.
arteries or kidney involvement or function. In Disadvantages. The technique is opera-
addition, its sensitivity and specificity vary tor-dependent and is less reliable in obese sub-
from center to center and are reduced in jects.
C L E V E L A N D C L I N I C J O U R N A L OF M E D I C I N E V O L U M E 67 • N U M B E R 5 MAY 2000 3 1 9
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