Resistant Hypertension with Renal Artery Stenosis Management

Initial Management Approach

The American Heart Association recommends medical therapy as the Class I (Level A) treatment for atherosclerotic renal artery stenosis, which must be optimized before considering revascularization 1, 2, 3, 4.
Medical management should include a renin-angiotensin system (RAS) blocker, high-intensity statin, low-dose aspirin, and additional antihypertensive agents to achieve blood pressure <130/80 mmHg 5.
The American Journal of Kidney Diseases suggests that ACE inhibitor or ARB treatment in patients with identified renal artery stenosis confers a long-term mortality benefit 6.
Most patients (80-90%) with renovascular disease tolerate ACE inhibitor or ARB therapy without adverse renal effects, though 10-20% may develop a rise in serum creatinine 7.

The American Journal of Kidney Diseases recommends referral to a physician with expertise in secondary hypertension for diagnostic confirmation and treatment if an adult with sustained hypertension screens positive for a form of secondary hypertension (Class IIb, Level C-EO) 2, 3, 4.
Patients with chronic kidney disease and resistant hypertension are at higher risk for cardiovascular events and renal events compared with patients with chronic kidney disease without resistant hypertension 7.
Referral to a nephrologist is recommended when medical management has failed, defined as refractory/resistant hypertension despite three appropriate blood pressure medications at maximally tolerated doses, worsening renal function, intractable heart failure, or progressive chronic kidney disease with bilateral renal artery stenosis or stenosis to solitary functioning kidney 1, 2, 3, 4, 8.

Nephrologists have specific expertise in managing the challenging balance between blood pressure control and preservation of renal function in patients with renal artery stenosis 7.
The American Journal of Kidney Diseases suggests that primary aldosteronism is present in up to 20% of individuals with resistant hypertension and is frequently overlooked 2, 3, 4.

The American Heart Association recommends optimizing medical therapy before proceeding to revascularization, which is the Class I recommendation 1, 2, 3, 4, 5, 8.
A rise in serum creatinine during ACE inhibitor or ARB treatment in patients with renal artery stenosis is often transient and related to sluggish renal autoregulation when blood pressure falls 6.
Assessment of kidney viability is critical before revascularization, and signs of viability include kidney size >8 cm, distinct cortex >0.5 cm, albumin-creatinine ratio <20 mg/mmol, and renal resistance index <0.8 5.