PANCE Blueprint Renal System (5%)

Patient will present as → a 67-year-old female with a history of hypertension, hyperlipidemia, and coronary artery disease presents to the clinic with poorly controlled blood pressure despite being on three antihypertensive medications. She reports frequent headaches and dizziness and notes that her blood pressure has been fluctuating for the past few months. On physical examination, her blood pressure is 180/95 mmHg, and there is an audible abdominal bruit over the epigastric area. Laboratory results show a mild elevation in serum creatinine. A renal duplex ultrasound reveals significant renal artery stenosis. Further evaluation with CT angiography confirms a 70% narrowing of the left renal artery. The patient is diagnosed with renal vascular disease, specifically renal artery stenosis, likely secondary to atherosclerosis. Management includes lifestyle modifications such as smoking cessation, a heart-healthy diet, and regular exercise. Medications, including statins, are started to reduce cholesterol, and antihypertensive therapy is optimized. Given the severity of stenosis and her uncontrolled blood pressure, the patient is referred for percutaneous transluminal renal angioplasty (PTRA) with or without stent placement. Long-term follow-up includes monitoring of renal function, blood pressure, and the success of revascularization.

Renal artery bruit (with bowel sounds)

Renal artery stenosis is the narrowing of one or both renal arteries, most often caused by atherosclerosis or fibromuscular dysplasia

• Narrowing of the renal artery can impede blood flow to the target kidney
• The reduced blood flow is interpreted by the kidneys as a sign of low blood pressure, triggering the renin-angiotensin-aldosterone system (RAAS). This leads to increased sodium and water retention and vasoconstriction, ultimately resulting in renovascular hypertension (a secondary type of high blood pressure)

May hear a renal artery bruit on auscultation

• Patients may present with HTN before age 30, HTN with CAD or PVD history, Hypertension resistant to three or more drugs
• If a patient is placed on an ACE inhibitor and suddenly develops acute renal failure or a sharp rise in BUN/CR, you should think of renal artery stenosis

Renal Doppler ultrasound is often initial imaging in those < 60 years of age with suspected RAS

• Renal arteriography is the GOLD STANDARD for diagnosis

Renal arteriography demonstrating renal artery stenosis

Stenting of renal arteries

• Treatment is with percutaneous transluminal angioplasty (PTA) plus stent placement or with surgical bypass of the stenotic segment
• Usually, an extensively infarcted kidney must be removed if revascularization is not expected to result in functional recovery
• In patients with renal artery stenosis, especially those with stable renal function, the most appropriate initial management is medical management with antihypertensive medications
  • ACE inhibitors and ARBs can be used in unilateral and, if glomerular filtration rate (GFR) is monitored closely, in bilateral renal artery stenosis
  • Additional antihypertensive medications are frequently required