Many histopathologic findings within post-stenotic kidneys are nonspecific and represent conditions associated with aging, atherosclerosis and pre-existing hypertension. Two major abnormalities reported in patients with renovascular disease (RVD) are arteriolar nephrosclerosis and atheroembolic renal lesions. Other chronic renal “ischemia” markers include tubular atrophy, interstitial fibrosis and arteriolar sclerosis, but are less specific.
Recent data demonstrate that intra-renal oxygenation in renovascular disease (RVD) is affected in a patchy way and produces local alterations that can ultimately lead to irreversible tissue damage. Moreover, kidney injury has the tendency for progressive deterioration even after the primary causal factor is eliminated.
Transvenous or transjugular renal biopsy, requiring retrograde access through the venous system, was recently proposed as an alternative for patients with contraindications for percutaneous biopsy. This technique was used in a prospective study to examine histopathologic changes in biopsies from kidneys with moderate unilateral renal artery stenosis, compared with renal tissue specimens from normal kidney donors, and nephrectomy samples for total vascular occlusion. Tissue from affected kidneys has provided evidence for complex injury pathways in atherosclerotic RVD that include activation of Transforming Growth Factor-β (TGF- β) and accumulation of tissue macrophages in addition to progressive interstitial fibrosis. These data support a transition from a hemodynamic disorder to one with inflammatory and fibrotic injury that does not reverse entirely with restoration of blood flow alone.
Direct examination of kidney tissue obtained by biopsy might contribute to both understand the disease process and to identify those individuals likely to benefit (or not) from measures to restore blood flow or other treatment modalities.
Stewart BH, Dustan HP, Kiser WS, Meaney TF, Straffon RA, McCormack LJ. Correlation of angiography and natural history in evaluation of patients with renovascular hypertension. J Urol. 1970;104:231–8.PubMedGoogle Scholar
Schreiber MJ, Pohl MA, Novick AC. The natural history of atherosclerotic and fibrous renal artery disease. Urol Clin North Am. 1984;11:383–92.PubMedGoogle Scholar
Tollefson DF, Ernst CB. Natural history of atherosclerotic renal artery stenosis associated with aortic disease. J Vasc Surg. 1991;14:327–31.PubMedCrossRefGoogle Scholar
Zierler RE, Bergelin RO, Isaacson JA, Strandness Jr DE. Natural history of atherosclerotic renal artery stenosis: a prospective study with duplex ultrasonography. J Vasc Surg. 1994;19:250–7; discussion 7–8.PubMedCrossRefGoogle Scholar
de Mast Q, Beutler JJ. The prevalence of atherosclerotic renal artery stenosis in risk groups: a systematic literature review. J Hypertens. 2009;27:1333–40.PubMedCrossRefGoogle Scholar
Harding MB, Smith LR, Himmelstein SI, et al. Renal artery stenosis: prevalence and associated risk factors in patients undergoing routine cardiac catheterization. J Am Soc Nephrol. 1992;2:1608–16.PubMedGoogle Scholar
Corradi B, Malberti F, Farina M, et al. Chronic renal failure due to atheromatous renovascular disease in the elderly. Contrib Nephrol. 1993;105:167–71.PubMedGoogle Scholar
Novick AC, Ziegelbaum M, Vidt DG, Gifford Jr RW, Pohl MA, Goormastic M. Trends in surgical revascularization for renal artery disease. Ten years’ experience. JAMA. 1987;257:498–501.PubMedCrossRefGoogle Scholar
Zinman L, Libertino JA. Revascularization of the chronic totally occluded renal artery with restoration of renal function. J Urol. 1977;118:517–21.PubMedGoogle Scholar
Schefft P, Novick AC, Stewart BH, Straffon RA. Renal revascularization in patients with total occlusion of the renal artery. J Urol. 1980;124:184–6.PubMedGoogle Scholar
Dean RH, Tribble RW, Hansen KJ, O’Neil E, Craven TE, Redding 2nd JF. Evolution of renal insufficiency in ischemic nephropathy. Ann Surg. 1991;213:446–55; discussion 55–6.PubMedCentralPubMedCrossRefGoogle Scholar
Wright JR, Duggal A, Thomas R, Reeve R, Roberts IS, Kalra PA. Clinicopathological correlation in biopsy-proven atherosclerotic nephropathy: implications for renal functional outcome in atherosclerotic renovascular disease. Nephrol Dial Transplant. 2001;16:765–70.PubMedCrossRefGoogle Scholar
Lopez-Novoa JM, Rodriguez-Pena AB, Ortiz A, Martinez-Salgado C, Lopez Hernandez FJ. Etiopathology of chronic tubular, glomerular and renovascular nephropathies: clinical implications. J Transl Med. 2011;9:13.PubMedCentralPubMedCrossRefGoogle Scholar
Moran K, Mulhall J, Kelly D, et al. Morphological changes and alterations in regional intrarenal blood flow induced by graded renal ischemia. J Urol. 1992;148:463–6.PubMedGoogle Scholar
Eddy AA. Interstitial fibrosis in hypercholesterolemic rats: role of oxidation, matrix synthesis, and proteolytic cascades. Kidney Int. 1998;53:1182–9.PubMedCrossRefGoogle Scholar
Wu XQ, Kong X, Zhou Y, Huang K, Yang JR, Li XL. Sesamin exerts renoprotective effects by enhancing NO bioactivity in renovascular hypertensive rats fed with high-fat-sucrose diet. Eur J Pharmacol. 2012;683:231–7.PubMedCrossRefGoogle Scholar
Cheng J, Zhou W, Warner GM, et al. Temporal analysis of signaling pathways activated in a murine model of two-kidney, one-clip hypertension. Am J Physiol Renal Physiol. 2009;297:F1055–68.PubMedCentralPubMedCrossRefGoogle Scholar
Warner GM, Cheng J, Knudsen BE, et al. Genetic deficiency of Smad3 protects the kidneys from atrophy and interstitial fibrosis in 2K1C hypertension. Am J Physiol Renal Physiol. 2012;302:F1455–64.PubMedCentralPubMedCrossRefGoogle Scholar
Chade AR, Rodriguez-Porcel M, Grande JP, et al. Mechanisms of renal structural alterations in combined hypercholesterolemia and renal artery stenosis. Arterioscler Thromb Vasc Biol. 2003;23:1295–301.PubMedCrossRefGoogle Scholar
Chade AR, Rodriguez-Porcel M, Herrmann J, et al. Antioxidant intervention blunts renal injury in experimental renovascular disease. J Am Soc Nephrol. 2004;15:958–66.PubMedCrossRefGoogle Scholar
Favreau F, Zhu XY, Krier JD, et al. Revascularization of swine renal artery stenosis improves renal function but not the changes in vascular structure. Kidney Int. 2010;78:1110–8.PubMedCentralPubMedCrossRefGoogle Scholar
Keddis MT, Garovic VD, Bailey KR, Wood CM, Raissian Y, Grande JP. Ischaemic nephropathy secondary to atherosclerotic renal artery stenosis: clinical and histopathological correlates. Nephrol Dial Transplant. 2010;25:3615–22.PubMedCentralPubMedCrossRefGoogle Scholar
Lakin PC, Pavcnik D, Bloch RD, et al. Percutaneous transjugular kidney biopsy in swine with use of a side-cutting needle with a blunt-tipped stylet. J Vasc Interv Radiol. 1999;10:1229–32.PubMedCrossRefGoogle Scholar
Cluzel P, Martinez F, Bellin MF, et al. Transjugular versus percutaneous renal biopsy for the diagnosis of parenchymal disease: comparison of sampling effectiveness and complications. Radiology. 2000;215:689–93.PubMedCrossRefGoogle Scholar
Rychlik I, Petrtyl J, Tesar V, Stejskalova A, Zabka J, Bruha R. Transjugular renal biopsy. Our experience with 67 cases. Kidney Blood Press Res. 2001;24:207–12.PubMedCrossRefGoogle Scholar
Misra S, Gyamlani G, Swaminathan S, et al. Safety and diagnostic yield of transjugular renal biopsy. J Vasc Interv Radiol. 2008;19:546–51.PubMedCrossRefGoogle Scholar
Levi IM, Ben-Dov IZ, Klimov A, Pizov G, Bloom AI. Transjugular kidney biopsy: enabling safe tissue diagnosis in high risk patients. Isr Med Assoc J. 2011;13:425–7.PubMedGoogle Scholar
Ahmed MS, Patel A, Borge MA, Picken MM, Leehey DJ. Simultaneous transjugular renal biopsy and hemodialysis catheter placement in patients with ARF. Am J Kidney Dis. 2004;44:429–36.PubMedCrossRefGoogle Scholar