Renal artery stenosis: symptoms

Symptoms of stenosis of the renal arteries are not sufficiently specific; At the same time, in the detection of a combination of symptoms, further examination, especially the use of imaging techniques, is necessary to confirm atherosclerotic stenosis of the renal arteries.

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

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

Atherosclerotic Renovascular hypertension is characterized by prognostically unfavorable variants of the circadian rhythm of arterial pressure, characterized by an insufficient decrease in it or a further increase at night. It is also characterized by more severe lesions of target organs than with essential arterial hypertension and a high incidence of associated clinical conditions (cerebral stroke, chronic heart failure). Atherosclerotic Renovascular Hypertension always belongs to the category of high or very high risk of complications in the classifications of the European Society of Hypertension (2003) and the All-Russian Scientific Society of Cardiology (2005).

Atherosclerotic stenosis of the renal arteries, as a rule, hypercreatininemia, more often mild, and therefore erroneously regarded as a sign of "involutive" changes in the renal tissue, but which sometimes increases rapidly with the action of the corresponding factors, is usually revealed. ACE inhibitors and angiotensin II receptor blockers, as well as NSAIDs, primarily provoke hyperkalemia, often outstripping the growth of serum creatinine.

Embolism of the intrarenal arteries and arterioles with cholesterol crystals causes a rapidly progressing loss of kidney function; sometimes diuresis is steadily decreasing up to anuria. Possible pain in the lumbar region, transient hematuria, leukocyturia (a pool of leukocytes falling into the urine, is represented mainly by ezosinophils). As a rule, a pronounced and practically non-curable rise in arterial pressure with signs of malignancy, including edema of the optic nerve disk, is noted. The signs of embolism of other visceral branches of the aorta often come to the fore in the clinical picture. Cholesterol embolism of the intrarenal arterioles can be acute (acute renal failure with anuria, usually irreversible and often fatal), subacute (impaired renal function and extrarenal manifestations are not so pronounced) and chronic (recurrent embolic episodes causing gradual increase in renal failure). In acute cholesterol embolism, the "general" symptoms are most pronounced, less noticeable in other forms:

• fever;
• pain in the muscles;
• loss of body weight;
• lack of appetite, weakness;
• itching;
• acceleration of ESR;
• increase in serum levels of C-reactive protein;
• hypofibrinogenemia;
• hypereosinophilia;
• hypocompleteemia (not always observed).

Clinical symptoms of embolism of the intrarenal arteries and arterioles with cholesterol crystals

Localization of emboli	Symptoms
Arteries of the brain	Difficult tolerable headache Nausea, vomiting, not bringing relief Disorders of consciousness Transient ischemic attack / cerebral stroke
Arteries of the retina	Failure of visual fields / blindness Bright-yellow plaques of Hollenhorst on the retina Hemorrhages Edema of the optic nerve
Arteries of the digestive system	"Ischemic" intestinal pain Dynamic intestinal obstruction Gastrointestinal bleeding Gangrene bowel loops Acute pancreatitis, including with destruction
Arteries of the kidneys	Pain in the lumbar region Oligo- and anuria Reduction of GFR, hypercreatininaemia Hyperkalemia Hematuria, leukocyturia (eosinophiluria)
Arteries of the skin (especially the lower limbs)	The mesh guide Trophic ulcers

Atherosclerotic stenosis of the renal arteries is almost always combined with other manifestations of a common and often complicated atherosclerosis:

• IHD (including those with acute myocardial infarction, acute coronary syndrome, coronary angiography and / or coronaroangioplasty procedures);
• transient ischemic attacks and / or acute disorders of cerebral circulation, clinically obvious or asymptomatic atherosclerotic lesion of carotid arteries;
• syndrome of intermittent claudication;
• Atherosclerotic lesions of the abdominal aorta, including aneurysm.

Especially often, severe ischemic heart disease, atherosclerotic carotid artery disease (including asymptomatic carotid artery disease) and intermittent claudication syndrome are combined with atherosclerotic renovascular hypertension.

Patients suffering from ischemic kidney disease often observe severe heart failure, whose treatment options are severely limited due to the inability to administer RAAS blockers and diuretics in adequate doses. At the peak of the hypertensive crisis in atherosclerotic stenosis of the renal arteries, difficult-to-resolve episodes of pulmonary edema can often develop, often recurring.

It should be borne in mind the possibility of combining atherosclerotic stenosis of the renal arteries with other chronic nephropathies, especially metabolic (diabetic, urate), considered to be typical for the elderly (analgesic nephropathy, chronic pyelonephritis), and long-term chronic glomerulonephritis and kidney stone disease. To suspect ischemic kidney disease in this situation, the features of arterial hypertension (the increase in its severity in the absence of obvious causes), renal failure (aggravation in the appointment of ACE inhibitors or angiotensin II receptor blockers in the absence of signs of activity of the initial kidney disease), as well as a combination of cardiovascular factors risk and signs of the prevalence of the atherosclerotic process.

[1], [2], [3], [4]