Renal artery stenosis: treatment

Treatment of renal artery stenosis (ischemic kidney disease) is as follows:

• minimization of the number of medicines used (if possible, elimination of NSAIDs, antibacterial and antifungal drugs);
• administration of statins (possibly in combination with ezetimibe);
• abolition of ACE inhibitors and angiotensin II receptor blockers;
• optimization of diuretic use (prevention of forced diuresis);
• if possible, early use of invasive treatments.

Prospects of antihypertensive therapy for atherosclerotic stenosis of the renal arteries are limited by the inability to use ACE inhibitors and angiotensin II receptor blockers (even with absolute indications, for example, in chronic heart failure or type 2 diabetes mellitus) and thiazide diuretics that lose effectiveness with persistent GFR decline. All patients suffering from ischemic kidney disease need nevertheless in combined antihypertensive therapy. As long-acting blockers of slow calcium channels in combination with cardioselective beta adrenoblockers, P-imidazoline receptor agonists, alpha-adrenoblockers and loop diuretics can be used as basic drugs. A sharp drop in blood pressure is undesirable; titration of doses of antihypertensive drugs should be carried out under the control of serum levels of creatinine and potassium. Achieving general population target blood pressure (<140/90 mmHg) with atherosclerotic stenosis of the renal arteries can be dangerous due to aggravation of renal tissue hypoperfusion.

All patients with ischemic kidney disease are absolutely statins. With severe lipoprotein metabolism disorders (for example, when hypercholesterolemia and hypertriglyceridemia are combined), they can be combined with ezetimibe. Obligatory medical correction of other metabolic disorders: insulin resistance and type 2 diabetes mellitus, hyperuricemia; Its tactics are limited by the need to change the doses of most drugs (eg, allopurinol), based on the degree of reduction in GFR.

Active prevention of cardiovascular complications in atherosclerotic stenosis of the renal arteries implies the appointment of acetylsalicylic acid and / or clopidogrel. The patterns of their use, apparently, do not differ from those generally accepted in IHD, but require special study in patients with atherosclerotic renovascular hypertension in terms of safety.

Conservative treatment of renal artery stenosis is always ineffective, since it does not allow to achieve neither control over arterial pressure nor stabilization of renal function. That is why early revascularization of the kidneys is justified, although in most patients after it is observed a decrease, but not a normalization of arterial pressure and creatinineemia. Balloon dilatation of the renal arteries is quickly accompanied by restenosis, and therefore stent implantation is always justified. The risk of restenosis inside the stent increases baseline high systolic blood pressure, pronounced hypercreatinemia, elderly age and hyperfibrinogenemia. The advantage of stents coated with rapamycin, with atherosclerotic stenosis of the renal arteries, in contrast to IHD, has not yet been proved. Shunting of the renal arteries is performed if stenting or ineffectiveness of previously performed stenting is impossible; this intervention is difficult due to the presence of concomitant diseases, including cardiovascular diseases.

Angioplasty is the only treatment method that reliably improves the prognosis for atherosclerotic stenosis of the renal arteries; after it has been carried out, the patients, nevertheless, continue to need aggressive secondary prophylaxis of cardiovascular complications, which also seems to reduce the likelihood of restenosis inside the stent. The optimal tactics for prescribing antiplatelet agents (including IIb / IIIa blockers of platelets and clopidogrel) and anticoagulants (including low molecular weight heparins) in the immediate period after the intervention on the renal arteries needs further clarification and can not be completely borrowed from the generally accepted in CHD .

Approaches to the treatment of cholesterol embolism of the intrarenal arteries and arterioles are practically not developed. The severity of acute renal failure may result in the implementation of emergency hemodialysis. Presumably, statins are shown, and with pronounced immuno-inflammatory manifestations (including acute eosinophilic tubulointerstitial nephritis) - corticosteroids in high doses. The efficacy of these methods of treating renal artery stenosis in controlled clinical trials has not been studied.

With the development of terminal renal failure, program hemodialysis or a permanent ambulatory PD begins. Kidney transplantation in atherosclerotic stenosis of the renal arteries is not performed. Treatment nephrectomy should be discussed only with established kidney atrophy and the impossibility of lowering blood pressure with medications and / or acquiring arterial hypertension features of malignancy.

[1], [2]