Skip to main content

Advertisement

SpringerLink
Log in

An evidence-based approach to diagnosing renovascular hypertension

  • Published:
Current Cardiology Reports Aims and scope Submit manuscript

Abstract

Making the diagnosis of potentially reversible renovascular hypertension can be problematic. Although there are a number of noninvasive screening tests available, no one study is appropriate for every patient. In general, the available tests can be divided into those that identify the functional consequences of a renal artery obstruction (angiotensin-converting enzyme inhibitor-augmented renography) and those that identify the anatomic presence of stenosis (duplex ultrasonography, magnetic resonance angiography, and contrast tomography angiography). The most appropriate diagnostic approach is based largely on the clinical index of suspicion, the potential etiology of the renal artery lesion (fibromuscular dysplasia or atherosclerosis), and the individual patient’s physiology and presentation. A potential treatment algorithm is presented.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

  1. Mann SJ, Pickering TG: Detection of renovascular hypertension: state of the art 1992. Ann Intern Med 1992, 117:845–853.

    PubMed  CAS  Google Scholar 

  2. Bloch MJ, Pickering TG: Renal vascular disease: medical management, angioplasty, and stenting. Sem Nephrol 2000, 20:474–488. This comprehensive review examines the available medical and therapeutic options for the management of renal vascular disease. Although large, quality, prospective randomized trials are lacking, the authors conclude that aggressive medical management (with blood pressure control and careful surveillance of renal function) may be a reasonable approach in certain patients.

    CAS  Google Scholar 

  3. Bloch MJ, Trost DW, Sos TA, et al.: Prevention of recurrent pulmonary edema in patients with bilateral renal artery stenosis through endovascular stent placement. Hypertension 1999, 12:1–7.

    CAS  Google Scholar 

  4. Krijnen P, van Jaarsveld BC, Steyerberg EW, et al.: A clinical prediction rule for renal artery stenosis. Ann Intern Med 1998, 129:705–711. In the DRASTIC study, a regression model was developed using the clinical characteristics of 477 hypertensive patients who underwent conventional angiography for evaluation of possible renovascular hypertension. Age, sex, atherosclerotic vascular disease, recent onset of hypertension, smoking history, body mass index, abdominal bruit, serum creatinine, and serum cholesterol were selected as the main predictors. The regression model discriminated well between patients with stenosis and those with essential hypertension. In a separate analysis, this model was found to have similar accuracy to renal scintigraphy.

    PubMed  CAS  Google Scholar 

  5. vanJaarsveld BC, Krijnen P: Prospective studies of diagnosis and intervention: the Dutch experience. Sem in Nephrol 2000, 20:463–473.

    Google Scholar 

  6. Reiss MD, Bookstein JJ, Bleifer KH: Radiologic aspects of renovascular hypertension: part 4; angiographic complications. JAMA 1972, 221:374–378.

    Article  Google Scholar 

  7. Muller FB, Sealey JE, Case CB, et al.: The captopril test for identifying renovascular disease in hypertensive patients. Am J Med 1986, 80:633–644.

    Article  PubMed  CAS  Google Scholar 

  8. Vaughan ED, Buhler FR, Laragh JH, et al.: Renovascular hypertension: renin measurements to indicate hypersecretion and contralateral suppression, estimate renal plasma flow, and score for surgical curability. Am J Med 1973, 55:402–414.

    Article  PubMed  Google Scholar 

  9. Ugur O, Serdengecti M, Karacalioglu O, et al.: Comparison of tc-99m ec and tc-99m dtpa captopril scintigraphy to diagnose renal artery stenosis. Clin Nuc Med 1999, 24:553–560.

    Article  CAS  Google Scholar 

  10. Wenting GJ, Tan-Tijong HL, Derkx FHM, et al.: Split renal function after captopril in unilateral renal artery stenosis. Br Med J 1984, 288:886–890.

    Article  CAS  Google Scholar 

  11. Fommei E, Ghione S, Hilson AJ, et al.: Captopril radionuclide test in renovascular hypertension: European multicentre study group. Eur J Nucl Med 1993, 20:617–623.

    Article  PubMed  CAS  Google Scholar 

  12. VanJaarsveld BC, Krijnen P, Derkx FH, et al.: The place of renal scintigraphy in the diagnosis of renal artery stenosis: fifteen years of clinical experience. Arch Intern Med 1997, 157:1226–1234.

    Article  CAS  Google Scholar 

  13. Setaro JF, Saddler MC, Chen CC, et al.: Simplified captopril renography in diagnosis and treatment of renal artery stenosis. Hypertension 1991, 18:289–298.

    PubMed  CAS  Google Scholar 

  14. Taylor A, Nally J, Aurell M, et al.: Consensus report on ACEinhibitor renography for detecting renovascular hypertension: radionucleotides in nephrology group: consensus group on ACEi renography. J Nucl Med 1996, 37:1876–1882.

    PubMed  CAS  Google Scholar 

  15. Burns PN: The physical principles of Doppler and spectral analysis. J Clin Ultrasound 1987, 15:567–590.

    Article  PubMed  Google Scholar 

  16. Hansen KJ, Tribble RW, Reavis et al.: Renal duplex sonography: evaluation of clinical utility. J Vasc Surg 1990, 12:227–236.

    Article  PubMed  CAS  Google Scholar 

  17. Olin JW, Piedmonte MA, Young JR, et al.: The utility of duplex ultrasound scanning of the renal arteries for diagnosing significant renal artery stenosis. Ann Intern Med 1995, 122:833–838.

    PubMed  CAS  Google Scholar 

  18. Taylor DC, Kettler MD, Moneta GL, et al.: Duplex ultrasound scanning in the diagnosis of renal artery stenosis: a prospective evaluation. J Vasc Surg 1988, 7:363–369.

    Article  PubMed  CAS  Google Scholar 

  19. Hoffmann U, Edwards JM, Carter S, et al.: Role of duplex scanning for the detection of atherosclerotic renal artery disease. Kidney Int 1991, 31:1232–1239.

    Google Scholar 

  20. Desberg AL, Paushter DM, Lammert GK, et al.: Renal artery stenosis: evaluation with color Doppler flow imaging. Radiology 1990, 177:749–753.

    PubMed  CAS  Google Scholar 

  21. Robertson R, Murphy A, Dubbins PA: Renal artery tenosis: the use of duplex ultrasound as a screening technique. Br J Radiol 1988, 61:196–201.

    Article  PubMed  CAS  Google Scholar 

  22. Mollo M, Pelet V, Mouawad J, et al.: Evaluation of colour duplex ultrasound scanning in diagnosis of renal artery stenosis compared to angiography: a prospective study on 53 patients. Eur J Vasc Endovasc Surg 1997, 14:305–309.

    Article  PubMed  CAS  Google Scholar 

  23. Nazzal MMS, Hoballah JJ, Miller EV, et al.: Renal hilar Doppler analysis is of value in the management of patients with renovascular disease. Am J Surg 1997, 174:164–168.

    Article  PubMed  CAS  Google Scholar 

  24. Halpern EJ, Needleman L, Nack TL, East SA: Renal artery stenosis: should we study the main renal artery or segmental vessels? Radiology 1995, 195:799–804.

    PubMed  CAS  Google Scholar 

  25. Johansson M, Jensen G, Aurell M: Evaluation of duplex ultrasound and captopril renography for detection of renovascular hypertension. Kidney Int 2000, 58:774–782. In a cohort of hypertensive patients with a relatively high prevalence of renal artery stenosis (19%), both DU and captopril renography were found to predict the results of subsequent angiography accurately. Positive predictive values were 76% for DU and 68% for renography. Negative predictive values were 96% for both studies. The prevalence of disease in this cohort is probably consistent with a real-world situation of moderate to high clinical suspicion.

    Article  PubMed  CAS  Google Scholar 

  26. Motew SJ, Cherr GS, Craven TE, et al.: Renal duplex sonography: main renal artery versus hilar analysis. J Vasc Surg 2000, 32(3):462–471. This study compared the accuracy of main renal artery Doppler scanning (direct) with hilar analysis (indirect) to diagnose hemodynamically significant renal artery disease. In the past few years, the enthusiasm for indirect hilar analysis has been increasing because this technique avoids a number of the potential drawbacks of traditional duplex scanning. However, this unique trial illustrated significantly decreased accuracy with the hilar technique.

    Article  PubMed  CAS  Google Scholar 

  27. Lencioni R, Pinto S, Napoli V, Bartolozzi C: Noninvasive assessment of renal artery stenosis: current imaging protocols and future directions in ultrasonography. J Computer Assist Tomog 1999, 23(Suppl 1):S95-S100.

    Google Scholar 

  28. Giroux MF, Soulez G, Therasse E, et al.: Relative predictive value of intra-renal Doppler sonography and scintigraphy for favorable clinical outcome after renal artery angioplasty and stenting [abstract]. Radiology 1998, 209(P):493.

    Google Scholar 

  29. Radermacher J, Chavan A, Bleek J, et al.: Use of Doppler ultrasonography to predict the outcome of therapy in renal artery stenosis. N Engl J Med 2001, 344:410–417. This unique study, which analyzed data from 5950 patients with suspected renovascular hypertension, found that an elevated resistive index (> 80) obtained by renal ultrasound reliably identifies patients with renal artery stenosis in whom angioplasty or surgery will not improve renal function, blood pressure, or kidney survival.

    Article  PubMed  CAS  Google Scholar 

  30. Bennett HF, Li D: MR imaging of renal function. MRI Clin North Am 1997, 5:107–126.

    CAS  Google Scholar 

  31. Kent KC, Edelman RR, Kim D, et al.: Magnetic resonance imaging: a reliable test for the evaluation of proximal atherosclerotic renal artery stenosis. J Vasc Surg 1991, 13:311–317.

    Article  PubMed  CAS  Google Scholar 

  32. Gedroyc WMW, Neerhut P, Negus R, et al.: Magnetic resonance angiography of renal artery stenosis. Clin Radiol 1995, 13:436–439.

    Article  Google Scholar 

  33. Soulez G, Liva VL, Turpin S, et al.: Imaging of renovascular hypertension: respective values of renal scintigraphy, renal Doppler US and MR angiography. Radiographics 2000, 20:1355–1368. This article outlines the contemporary methodology of ACE inhibitor scintigraphy, Doppler ultrasound, and MRA.

    PubMed  CAS  Google Scholar 

  34. DeCobelli E, Vanzuli A, Sironi S, et al.: Renal artery stenosis: evaluation with breath-hold, three-dimensional, dynamic, gadolinium-enhanced versus three-dimensional, phasecontrast MR angiography. Radiology 1997, 205:689–695.

    CAS  Google Scholar 

  35. Holland GA, Dougherty L, Carpenter JP, et al.: Breath hold ultrafast three dimensional gadolinium enhanced MR angiography of the aorta and the renal and other visceral abdominal arteries. Am J Roentgenol 1996, 166:971–981.

    CAS  Google Scholar 

  36. Rieumont MJ, Kaufman JA, Geller SC, et al.: Evaluation of renal artery stenosis with dynamic gadolinium enhanced MR angiography. Am J Roentgenol 1997, 169:39–44.

    CAS  Google Scholar 

  37. Leung DA, Hany TF, Debatin JF: Three-dimensional contrast enhanced magnetic resonance angiography of the abdominal arterial system. Cardiovasc Intervent Radiol 1998, 21:1–10.

    Article  PubMed  CAS  Google Scholar 

  38. Steffens JC, Link J, Grassner J, et al.: Contrast enhanced centered breath hold MR angiography of the renal arteries and the abdominal aorta. J Magn Reson Imaging 1997, 7:617–622.

    Article  PubMed  CAS  Google Scholar 

  39. Leung DA, Hoffmann U, Pfammatter T, et al.: Magnetic resonance angiography versus duplex sonography for diagnosing renovascular disease. Hypertens 1999, 33:726–729. The investigators in this study compared gadolinium-enhanced MRA with traditional duplex Doppler in the diagnosis of anatomically significant renal artery stenosis (> 60% on subsequent angiography). Both techniques showed excellent accuracy. Sensitivity and specificity for MRA were 90% and 86%, respectively; for duplex sonography, sensitivity and specificity were 81% and 87%. When patients with fibromuscular dysplasia were excluded, the sensitivity of MRA increased to 97%. MRA was far superior in detecting accessory renal arteries.

    CAS  Google Scholar 

  40. Kaatee R, Beek FJ, de Lange EE, et al.: Renal artery stenosis: detection and quantification with spiral CT angiography versus optimized digital subtraction angiography. Radiology 1997, 205:121–127.

    PubMed  CAS  Google Scholar 

  41. Cikrit DF, Harris VJ, Hemmer CJ, et al.: Comparison of spiral CT scan and arteriography for evaluation of renal and visceral arteries. Ann Vasc Surg 1996, 10:109–116.

    Article  PubMed  CAS  Google Scholar 

  42. Farres MT, Lammer J, Schima W, et al.: Spiral computed tomographic angiography of the renal arteries: a prospective comparison with intravenous and intra-arterial digital subtraction angiography. Cardiovasc Interv Radiol 1996, 19:101–106.

    Article  CAS  Google Scholar 

  43. Olbricht CJ, Prokop M, Chavan A, et al.: Minimally invasive diagnosis of renal artery stenosis by spiral computed tomography angiography. Kidney Int 1995, 48:1332–1337.

    Article  PubMed  CAS  Google Scholar 

  44. Beregi JP, Elkohen M, Deklunder G, et al.: Helical CT angiography compared with arteriography in the detection of renal artery stenosis. Am J Roentgenol 1996, 167:495–501.

    CAS  Google Scholar 

  45. Romero JC, Lerman LO: Novel techniques for studying renal function in man. Sem Nephrol 2000, 20:456–462.

    CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. University of Nevada School of Medicine, VAMC #111, 1000 Locust Street, 89520, Reno, NV, USA

    Michael J. Bloch MD

Authors
  1. Michael J. Bloch MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Bloch, M.J. An evidence-based approach to diagnosing renovascular hypertension. Curr Cardiol Rep 3, 477–484 (2001). https://doi.org/10.1007/s11886-001-0070-5

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11886-001-0070-5

Keywords

Search

Navigation