Atherosclerotic stenosis of the renal artery

Atherosclerotic renal artery stenosis (ischemic kidney disease, atherosclerotic renovascular hypertension) is a chronic kidney disease that manifests itself with signs of global renal hypoperfusion: decreased SCF, arterial hypertension, and increasing nephrosclerosis caused by hemodynamically significant narrowing of the main renal arteries by atherosclerotic plaques.

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Epidemiology

The exact prevalence of atherosclerotic stenosis of the renal arteries has not been established, since many cases of it remain unrecognized during life and are not recorded at autopsy due to the fact that the immediate cause of death of these patients is most often cardiovascular complications. In the registers of patients with ischemic kidney disease, including terminal, atherosclerotic stenosis of the renal arteries is often not taken into account, since in its presence hypertensive nephroangiosclerosis, latent chronic glomerulonephritis and other chronic nephropathies are often erroneously diagnosed, which are subsequently associated with irreversible deterioration of kidney function.

Nevertheless, it can already be stated that atherosclerotic stenosis of the renal arteries is one of the main causes of terminal renal failure in the elderly. Atherosclerotic stenosis of the renal arteries is the cause of at least 15% of all cases of irreversible deterioration of kidney function, recorded in the registers as their hypertensive lesion.

Atherosclerotic stenosis of the renal arteries is especially often found in patients with widespread and complicated atherosclerosis. Ischemic kidney disease is found in almost 10% of patients who undergo coronary angiography and abdominal aortography simultaneously, and in more than 15% of people who die from acute cerebrovascular accident.

The prevalence of atherosclerotic stenosis of the renal arteries is especially high in patients suffering from diabetes mellitus type 2 for a long time. Experience in analyzing autopsies performed in this category of patients indicates that the frequency of atherosclerotic stenosis of the renal arteries in them can reach 20-25%.

Of particular interest is the study of the epidemiology of atherosclerotic stenosis of the renal arteries in individuals seeking medical attention due to persistently elevated blood pressure. It has been established that atherosclerotic stenosis of the renal arteries accounts for at least 15% of all cases of arterial hypertension, including those initially considered essential and resistant to combination therapy with representatives of 2 classes of antihypertensive drugs.

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Causes atherosclerotic renal artery stenosis.

The cause of atherosclerotic renal artery stenosis is described by the concept of risk factors, which is generally accepted for other clinical variants of atherosclerosis. It is generally accepted that atherosclerotic renal artery stenosis is formed by a combination of several cardiovascular risk factors and their severity - "aggressiveness".

Old age is considered the main non-modifiable risk factor for atherosclerotic stenosis of the renal arteries, at which the probability of stenosing atherosclerotic lesions of the visceral branches of the aorta, including the renal arteries, increases many times over.

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Symptoms atherosclerotic renal artery stenosis.

The symptoms of renal artery stenosis are not very specific; however, if a combination of symptoms is detected, further examination is necessary, especially the use of imaging methods, to confirm atherosclerotic renal artery stenosis.

Arterial hypertension is a mandatory symptom of atherosclerotic stenosis of the renal arteries. The features of arterial hypertension typical for atherosclerotic stenosis of the renal arteries include:

• de novo occurrence in old age;
• loss of control over blood pressure, previously reduced with the use of standard antihypertensive therapy regimens;
• refractoriness to combination antihypertensive therapy;
• III degree (European Society of Hypertension, 2003; All-Russian Scientific Society of Cardiologists, 2005) arterial hypertension;
• predominant increase in systolic blood pressure.

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Forms

There is no generally accepted classification of atherosclerotic stenosis of the renal arteries. According to localization, there are:

• bilateral atherosclerotic stenosis of the renal arteries;
• predominantly unilateral atherosclerotic stenosis of the renal arteries;
• atherosclerotic stenosis of the artery of a single functioning kidney;
• atherosclerotic stenosis of the renal transplant artery.

In addition, ischemic kidney disease accompanied by occlusion of the renal artery should be considered separately.

The degree of decrease in SCF is described according to the classification of chronic kidney disease (NKF-DOQI, “Chronic Kidney Disease”).

Arterial hypertension in atherosclerotic stenosis of the renal arteries is characterized based on the generally accepted classification of the European Society of Hypertension (2003) and the All-Russian Scientific Society of Cardiologists (2005) (see “ Renal arterial hypertension ”).

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Diagnostics atherosclerotic renal artery stenosis.

Targeted search for atherosclerotic stenosis of the renal arteries is justified by the above-mentioned features of arterial hypertension, chronic renal failure, and the identification of signs of widespread atherosclerosis. Physical examination may reveal peripheral edema, manifestations of chronic heart failure (hepatomegaly, bilateral crepitations or moist rales in the basal parts of the lungs), as well as murmurs over the aorta and large vessels, including the renal vessels. The sensitivity and specificity of these symptoms are extremely low.

Changes in urine in atherosclerotic stenosis of the renal arteries are limited to “trace” proteinuria, often transient; hematuria and leukocyturia are not characteristic (with the exception of embolism of intrarenal arteries and arterioles by cholesterol crystals).

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Treatment atherosclerotic renal artery stenosis.

General principles of treatment of ischemic heart disease:

• minimizing the number of medications used (if possible, eliminating NSAIDs, antibacterial and antifungal drugs);
• prescribing statins (possibly in combination with ezetimibe);
• discontinuation of ACE inhibitors and angiotensin II receptor blockers;
• optimization of the diuretic regimen (prevention of forced diuresis);
• if possible, early use of invasive treatment methods.

Forecast

Atherosclerotic renal artery stenosis is a steadily progressing disease. Many patients, however, do not survive to terminal renal failure, dying from cardiovascular complications. The life expectancy of patients with atherosclerotic renovascular hypertension undergoing programmed hemodialysis is significantly lower compared to those suffering from other chronic kidney diseases; cardiovascular complications also predominate among the causes of death. The prognosis for cholesterol embolism of intrarenal arteries and arterioles is usually unfavorable.

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