What are the guideline sources, guidelines and references for Renal artery stenosis ?
Guideline sources The following summarized guidelines for the evaluation and management of renal artery stenosis are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2021), the Japanese Society of Nephrology (JSN 2019), the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA 2018), the Canadian Hypertension Education Program (CHEP 2018), and the European Society of Cardiology (ESC/ESVS 2018). 1 2 3 4 5 Guidelines 1. Screening and diagnosis Indications for screening: As per ESC 2018 guidelines, consider evaluating patients with flash pulmonary edema for renal artery disease. C https://web.pathway.md/diseases/recYUL5AewwlAfBcQ 1/5 6/24/23, 2:57 PM Renal artery stenosis Pathway As per AHA 2018 guidelines, screen for renovascular hypertension using renal Doppler ultrasound, MRA, or abdominal CT in the presence of the following clinical indications and physical examination findings: resistant hypertension, hypertension of abrupt onset or worsening or increasingly difficult to control, flash pulmonary edema (atherosclerotic), early-onset hypertension, especially in women (fibromuscular hyperplasia) abdominal systolic-diastolic bruit, bruits over carotid (atherosclerotic or FMD) or femoral arteries. B 2. Diagnostic investigations Renal artery imaging: Obtain duplex ultrasound as first-line imaging modality, or CT angiography (when estimated GFR is 60 mL/min) or MRA (when estimated GFR is 30 mL/min), to establish a diagnosis of renal artery disease. B Do not obtain renal scintigraphy for the evaluation of atherosclerotic renal artery disease. D Plasma renin: do not obtain plasma renin measurements before and after ACEI provocation and vein renin measurements for the evaluation of atherosclerotic renal artery disease. D 3. Diagnostic procedures Catheter-based contrast angiography: consider obtaining digital subtraction angiography to confirm a diagnosis of renal artery disease when clinical suspicion is high and the results of noninvasive examinations are inconclusive. C 4. Medical management Antihypertensive therapy: As per JSN 2019 guidelines, consider initiating RAAS inhibitors in patients with CKD with unilateral renal artery stenosis because it is superior in reducing BP in such patients compared to other antihypertensive drugs and may reduce progression to mortality, the onset of CVD, and progression of renal dysfunction. Adjust the dose carefully starting with a low dose and assessing the serum creatinine and potassium levels approximately 2 weeks after initiation to avoid the risk of AKI. Do not use a renin-angiotensin system inhibitor when bilateral renal artery stenosis is suspected. C As per CHEP 2018 guidelines, initiate pharmacotherapy in patients with hypertension attributable to atherosclerotic renal artery stenosis. Recognize that these patients do not benefit from renal angioplasty and stenting over optimal pharmacotherapy alone. B As per ESC 2018 guidelines, initiate ACEIs/ARBs for the treatment of patients with hypertension associated with unilateral renal artery stenosis. B https://web.pathway.md/diseases/recYUL5AewwlAfBcQ 2/5 6/24/23, 2:57 PM Renal artery stenosis Pathway Show 2 more Management of dyslipidemia: Offer statins in all patients with PADs. A Target reducing LDL cholesterol to < 1.8 mmol/L (< 70 mg/dL) or decreasing it by 50% if baseline values are 1.8-3.5 mmol/L (70-135 mg/dL). B Glycemic control: obtain strict glycemic control in patients with diabetes mellitus and PAD. B 5. Nonpharmacologic interventions Lifestyle modifications: advise smoking cessation B , healthy diet and physical activity in all patients with PADs. B 6. Therapeutic procedures Indications for revascularization: As per JSN 2019 guidelines, avoid performing revascularization in patients with CKD with arteriosclerotic renal artery stenosis due to the risk of complications because it does not suppress the progression of renal dysfunction or decrease the risk of developing CVD. D As per CHEP 2018 guidelines, consider performing revascularization in patients with hypertension attributable to FMD-related renal artery stenosis. C As per ESC 2018 guidelines, do not perform routine revascularization in patients with atherosclerotic renal artery stenosis. D Renal artery angioplasty: As per CHEP 2018 guidelines, perform renal artery angioplasty without stenting in patients with FMD-related renal artery stenosis. Do not perform stenting unless needed because of a periprocedural dissection. B Show 2 more Landmark trials: CORAL In people with atherosclerotic renal artery stenosis and either systolic hypertension while taking 2 antihypertensive drugs or CKD, renal artery stenting plus medical therapy was not superior to medical therapy alone with respect to death from any cause. Cooper CJ et al. N Engl J Med. 2014 Jan 2. As per ESC 2018 guidelines: Consider performing balloon angioplasty with bailout stenting in patients with hypertension and/or signs of renal impairment related to renal arterial FMD. C https://web.pathway.md/diseases/recYUL5AewwlAfBcQ 3/5 6/24/23, 2:57 PM Renal artery stenosis Pathway Consider performing balloon angioplasty with or without stenting in selected patients with renal artery stenosis and unexplained recurrent congestive HF or sudden pulmonary edema. C 7. Surgical interventions Surgical revascularization: As per CHEP 2018 guidelines, consider performing surgical revascularization in patients with complex lesions less amendable to angioplasty, stenosis associated with complex aneurysm, and restenosis despite two unsuccessful attempts of angioplasty. C As per ESC 2018 guidelines, consider performing surgical revascularization, if revascularization is indicated, in patients with complex anatomy of the renal arteries, after a failed endovascular procedure or during open aortic surgery. C 8. Specific circumstances Patients with transplant renal artery stenosis: suspect transplant renal artery stenosis in case of refractory arterial hypertension and/or increasing serum creatinine without hydronephrosis/infection. B Show 3 more 9. Quality improvement Hospital requirements: healthcare centers should set up a multidisciplinary vascular team to make decisions for the management of patients with PADs. B References 1. Paul K Whelton, Robert M Carey, Wilbert S Aronow et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018 Jun;71 6):e13-e115. Open 2. Butalia S, Audibert F, C t AM et al. Hypertension Canada's 2018 Guidelines for the Management of Hypertension in Pregnancy. Can J Cardiol. 2018 May;34 5 526 531. Open 3. Victor Aboyans, Jean-Baptiste Ricco, Marie-Louise E L Bartelink et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery ESVS Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization ESO The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology ESC and of the European Society for Vascular Surgery ESVS . Eur Heart J. 2018 Mar 1;39 9 763 816. Open https://web.pathway.md/diseases/recYUL5AewwlAfBcQ 4/5 6/24/23, 2:57 PM Renal artery stenosis Pathway 4. Japanese Society of Nephrology. Essential points from Evidence-based Clinical Practice Guidelines for Chronic Kidney Disease 2018. Clin Exp Nephrol. 2019 Jan;23 1 1 15. Open 5. A. Breda, K. Budde, A. Figueiredo et al. EAU Guidelines on Renal Transplantation. EAU. 2021. Open https://web.pathway.md/diseases/recYUL5AewwlAfBcQ 5/5