Which 2 things are causes of secondary hypertension? Which one is most common?
- Atherosclerotic RAS (MC)
- Fibromuscular dysplasia
Is it more common for renovascular disease (atherosclerotic RAS or Fibromuscular dysplasia) to be the cause of mild-mod elevated BP or in acute, severe, refractory HTN?
Acute, severe, refractory HTN
(< 1% of mild-mod elevated BP)
T/F: Renovascular disease is associated with target organ injury (LVH and renal fibrosis)
True
If a patient has the following, what disease should you consider?
1. HTN developed at young age
2. Severe or resistant
3. Acute rise over stable value
- Serum creatinine rises >30% after ACE/ARB
- Mod-severe HTN in pt with recurrent episodes of flash pulmonary edema
- Stage II HTN onset after age 55
- Mod-severe HTN in pt with diffuse atherosclerosis, unilateral small kidney, or asymmetric renal size (>1.5 cm)
- Abdominal bruit
Renovascular disease
What is the gold standard for diagnosing Renovascular disease? What test is actually performed in practice?
- Gold standard= Renal arteriography
- What you actually do= CT angio
**only test if intervention will be completed if a significant stenotic lesion is found**
Which renovascular disease is most common in people > 45y/o?
Atherosclerotic renal artery stenosis
Etiology of which renovascular disease?
- Reduced blood flow to kidney
- usually involves aortic orifice or proximal main renal artery
Atherosclerotic renal artery stenosis
What are the 3 risk factors for Atherosclerotic renal artery stenosis?
- Hyperlipidemia
- Cigarette smoking
- > 50y/o
What are 2 comorbidities often seen with atherosclerotic renal artery stenosis?
CAD or PAD
Atherosclerotic renal artery stenosis:
Diagnosis: ______ ______ of at least 60-75%
luminal occlusion of at least 60-75%
How do you treat atherosclerotic renal artery stenosis? (4 things)
- tx the HTN
- monitor CKD
- CV secondary prevention (smoking cessation, diet, etc)
- revascularization (angioplasty w/ or w/o stenting or bypass)
Which renovascular disease is MC in Women < 50y/o?
Fibromuscular dysplasia
Etiology of which renovascular disease?
•Noninflammatory, nonatherosclerotic disorder leading to arterial stenosis, occlusion, aneurysm, dissection, and arterial tortuosity – can effect nearly every arterial be
Fibromuscular dysplasia
What is the agiographic classification of fibromuscular dysplasia?
•multifocal (string of beads) vs. focal (circumferential or tubular stenosis)
(sting of beads is top pic, focal is bottom)
Which renovascular disease has the following clinical presentation?
1. HA
2. Pulsatile tinnitus
3. Neck pain
4. Flank or abdominal pain
- HTN
- Cervical or abdominal bruit
- TIA, stroke
Fibromuscular dysplasia
What is the medical management of fibromuscular dysplasia? What testing do you follow up with?
- ACE or ARB
- f/u w/ serum creatinine q 6 months and duplex U/S q 6-12 mo
What is surical management of fibromuscular dysplasia?
- Better success with angioplasty than RAS
What do you do after surgical managment of fibromuscular dysplasia?
Duplex u/s and serum creatinine at first post-op visit then q 6 months x 2 years then annually
What are the 2 management options of fibromuscular dysplasia?
- Medical management: ACE or ARB
- Surgical: Better success w/ angioplasty than RAS
What should you consider when giving an ACE/ARB for medical management of Renovascular disease?
- Renal perfusion decreased due to stenosis
- Autoregulation maintains GFR
- Medical blockade of angiotensin II formation blunts the effect of autoregulation—> reduced GFR—> possible AKI (hemodynamically induced)
What are 4 complications of surgicial treatment of renovascular disease?
- Renal artery dissection
- Capsular perforation
- Hemorrhage
- Atheroembolic disease – accelerates HTN and kidney failure
What 4 situations are most likely to benefit from surgical treatment of renovascular disease?
- Short duration of BP elevation prior to dx
- Failure of med therapy to control BP
- Intolerance to medical therapy
- Recurrent flash pulmonary edema and/or refractory heart failure
Fibromuscular dysplasia results in reduced blood flow to kidney and usually involves what 2 parts of the kidney?
Usually involves distal main renal artery or intrarenal branches
