Renovascular disease

Renovascular disease is common, and atherosclerotic renovascular disease (ARVD) accounts for 90% of renal artery stenosis (RAS) in Western populations, the remainder being due to fibromuscular disease (FMD). FMD usually presents as hypertension in young patients and there is often a successful response after angioplasty. ARVD is frequently associated with hypertension and renal dysfunction and is a disease of ageing. It is commonly diagnosed in patients who have atherosclerotic macrovascular disease in other parts of the body, such as those with coronary artery disease, peripheral vascular disease, cerebrovascular disease and aortic aneurysms. There is now good evidence to suggest that the cause of chronic renal dysfunction in most patients with ARVD is more often due to long-standing intra-renal vascular disease and parenchymal injury rather than to reversible ischaemia. This is reflected in the variability in renal functional outcome following revascularization, with an improvement in renal function being observed only in a minority of patients, and the majority showing no apparent change or even a decline in renal function. Over 95% of renal revascularization procedures are now percutaneous, but some of these procedures may not be performed in appropriate patients. Large-scale randomized controlled trials (such as ASTRAL) are required to determine overall outcomes, and more specifically, to help identify which sub-groups of patients will benefit from revascularization. Technological advances in imaging also offer potential in aiding this selection process.