Nephrol Dial Transplant (2003) 18: 443-444
© 2003 European Renal Association-European Dialysis and Transplant Association
Images in Nephrology
Kidney at risk: 11-year course of renal artery stenosis
Divisions of Nephrology, Cardiology and Nuclear medicine, Kantonsspital St Gallen, Switzerland
Keywords: coronary angiography; non-stenosing atherosclerotic plaques; renal artery stenosis
Case history
In 1990, a 49-year-old woman with unstable angina was admitted for coronary angiography, which showed two-vessel disease. She had a 33-year history of hypertension and so renal angiography was also performed which revealed a non-stenosing atherosclerotic plaque in the proximal left renal artery (Figure 1A
). Blood pressure was controlled with two antihypertensive drugs. The calculated creatinine clearance was 61 ml/min, and was unchanged since 1974.
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In 2001, aged 60, she was admitted again because of unstable angina. A coronary angiogram revealed three-vessel disease. Renal arteriography now showed a high-grade stenosis of the left renal artery where the plaque was seen 11 years before (Figure 1B
). Blood pressure was still well controlled with three antihypertensive drugs. Renal function was unchanged. Captopril scintigraphy with 99mTc-mercaptoacetyltriglycine (MAG3) showed equal perfusion of both kidneys, but severely impaired glomerular filtration on the left side indicated by massively enhanced tracer accumulation in a later phase (Figure 2A). This confirmed the haemodynamic significance of the angiographic finding. Percutaneous transluminal angioplasty with stent implantation was performed successfully (Figure 1C) with normalisation of the scintigraphic findings (Figure 2B), and reduction of antihypertensive treatment from three to one drugs.
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Discussion
Atherosclerotic renal artery disease causes renovascular hypertension and progressive kidney failure. Progression from a non-stenosing plaque to renal artery stenosis (>60% of diameter) occurs in 60% of patients over 5 years. Renal artery occlusion happens in less than 10% of patients within the same period [1]. Treatment options are aggressive antihypertensive and lipid-lowering therapy, percutaneous transluminal angioplasty with or without stent implantation, and surgical reconstruction. Revascularisation may prevent disease progression by restoration of arterial patency, but can cause renal infarction, contrast nephropathy or cholesterol embolism. Therefore the benefit of revascularisation and the optimal time of intervention is still a matter of debate [2,3], since no long-term follow up investigations are available.
Our patient illustrates: (i) the slow progression of atherosclerotic renal artery disease over 11 years with stable renal function for 25 years, after 35 years of well controlled hypertension; (ii) a different progression rate of atherosclerosis in coronary compared with renal arteries; (iii) the normalisation of angiographic and scintigraphic findings and reduction of antihypertensive treatment after angioplasty with stent implantation. We suggest careful follow-up of such patients with aggressive medical treatment of hypertension and hyperlipidaemia and with intervention only when renal artery occlusion is impending according to scintigraphic and angiographic findings.
Notes
Correspondence and offprint requests to: Dr. T. Fehr, Division of Nephrology, Kantonsspital, CH-9007 St. Gallen, Switzerland. E-mail: thomas.fehr{at}kssg.ch 
References
- Caps MT, Perissinotto C, Zierler RE et al. Prospective study of atherosclerotic disease progression in the renal artery. Circulation1998; 98:2866–2872
[Abstract/Free Full Text] - van Jaarsveld BC, Krijnen P, Pieterman H et al. The effect of balloon angioplasty on hypertension in atherosclerotic renal-artery stenosis. Dutch Renal Artery Stenosis Intervention Cooperative Study Group. N Engl J Med2000; 342:1007–1014
[Abstract/Free Full Text] - Plouin PF, Rossignol P, Bobrie G. Atherosclerotic renal artery stenosis: to treat conservatively, to dilate, to stent, or to operate? J Am Soc Nephrol2001; 12:2190–2196
[Free Full Text]
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