Renal artery stenosis diagnostic criteria: Difference between revisions
(/* 2013 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic) (DO NOT EDIT){{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis R...) |
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Catheter angiography is considered class I recommendation. It is the gold standard for the diagnosis of ARAS. Renal angiography may be used only if previous tests are equivocal and clinical suspicion is high or if the patient is already undergoing another catheterization process and consents to renal angiography. Generally, it is associated with a low frequency of adverse events.<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117 }} </ref> | Catheter angiography is considered class I recommendation. It is the gold standard for the diagnosis of ARAS. Renal angiography may be used only if previous tests are equivocal and clinical suspicion is high or if the patient is already undergoing another catheterization process and consents to renal angiography. Generally, it is associated with a low frequency of adverse events.<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117 }} </ref> | ||
== | ==Management of Patients With Peripheral Artery Disease (Compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations) : A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines<ref name="pmid23473760">{{cite journal| author=Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss L et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2013 | volume= 61 | issue= 14 | pages= 1555-70 | pmid=23473760 | doi=10.1016/j.jacc.2013.01.004 | pmc=4492473 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23473760 }} </ref>== | ||
===Clinical Clues to the Diagnosis of RAS (DO NOT EDIT)<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117 }} </ref>=== | ===Clinical Clues to the Diagnosis of RAS (DO NOT EDIT)<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117 }} </ref>=== | ||
Revision as of 14:19, 31 October 2016
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Renal artery stenosis Microchapters |
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Diagnosis |
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Treatment |
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Case Studies |
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Renal artery stenosis diagnostic criteria On the Web |
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American Roentgen Ray Society Images of Renal artery stenosis diagnostic criteria |
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Risk calculators and risk factors for Renal artery stenosis diagnostic criteria |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yazan Daaboul,Serge Korjian
Overview
Several clinical clues aid in the suspicion of ARAS and warrant further investigation. To date, imaging is considered the optimal modality to diagnose ARAS. According to the ACC/AHA guidelines in 2013, Doppler ultrasonography, CT angiography, and MR angiography are all non-invasive techniques to diagnose ARAS. Renal angiography remains the gold standard for diagnosis of ARAS. Nonethetheless, it is an invasive procedure that should be reserved to patients who are planning to perform a catheterization procedure and concede to renal angiography or to patients whose non-invasive imaging was equivocal.
Diagnosis
Indications for Work-Up
According to the 2013 ACC/AHA Guidelines for the Management of PAD[1], diagnostic work-up for renal artery stenosis is indicated in the following conditions:
Class I Recommendations[1]
- Hypertension of any stage before the age of 30
- Stage II hypertension (severe hypertension systolic blood pressure > 180 mm Hg or diastolic blood pressure > 120 mm Hg) in patients older than 55 years. If only mild hypertension is present, then renal artery stenosis is the underlying cause in only 1% of patients [2], but if the blood pressure is markedly elevated, then the risk of renal artery stenosis goes up 10 to 50 fold.
- Accelerated condition of previously controlled hypertension
- Resistant hypertension
- Malignant hypertension
- New azotemia (50% rise in creatinine that is sustained) within one week after administration of an Angiotensin Converting Enzyme (ACE)inhibitor or ARB
- Unexplained atrophic kidney or asymmetric kidneys that differ by > 1.5 cm. If the kidney is < 9 cm in size, there is a 75% chance that renal artery stenosis is present.
- Severe hypertension, impaired renal function, and recurrent flash pulmonary edema
Class IIa Recommendations[1]
- Unexplained renal failure including patients starting renal replacement therapy
Class IIb Recommendations[1]
- Presence of multi vessel CAD and no clinical clues of ARAS or PAD
- Unexplained CHF or refractory angina
Other Indications
- Severe hypertension in the presence of polyvascular disease (coronary artery disease or peripheral arterial disease)
- A unilateral systolic-diastolic abdominal bruit. Although a bruit is infrequent in documented renal artery stenosis (the sensitivity is only 40% percent) if it is auscultated, it is associated with a very high specificity of 99%.[3]
- The association of race with renal artery stenosis is not clear. Reports that it is observed more often in white patients may be due to reporting bias.[4]
Diagnostic Methods[1]
The best technique to diagnose atherosclerotic renal artery stenosis (ARAS) is by imaging. Assessment of both the main and the accessory renal arteries bilaterally is important for diagnostic purposes. Further evaluation should include the anatomic location of the stenosis, severity of stenosis, associated perirenal and perivascular pathologies, such as aneurysms or masses.[1] Duplex ultrasonography, computer tomographic angiography (CTA), magnetic resonance angiography (MRA), and catheter angiography are 4 techniques that are currently recommended for the diagnosis of ARAS.[1] In contrast, neither selective renal vein renin studies, captopril renal scintigraphy, plasma renin activity nor the captopril test are recommended anymore.[1]
Duplex Ultrasonography
Diagnosis by Duplex ultrasonography is considered class I recommendation. It may be used as an initial screening tool for diagnosis of ARAS. Ultrasonography might not be very accurate in obese patients or those with intestinal gas.[1]
Computed Tomographic Angiography
Diagnosis by CT angiography is considered class I recommendation. It provides higher spacial resolution compared to magnetic resonanc angiography (MRA). CT angiography may be used in patients with normal renal function to avoid contrast-induced nephropathy in patients with impaired renal function. Presence of previous stents or metallic objects are considered a contraindication for the use of CTA.[1]
Magnetic Resonance Angiography
Diagnosis by MRA is considered class I recommendation. Gadolinium-based MRA has less nephrotoxic characterstics with good visualization of the renal arteries and perirenal pathologies. Presence of previous stents or metallic objects are considered a contraindication for the use of MRA.[1]
Catheter Angiography
Catheter angiography is considered class I recommendation. It is the gold standard for the diagnosis of ARAS. Renal angiography may be used only if previous tests are equivocal and clinical suspicion is high or if the patient is already undergoing another catheterization process and consents to renal angiography. Generally, it is associated with a low frequency of adverse events.[1]
Management of Patients With Peripheral Artery Disease (Compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations) : A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines[5]
Clinical Clues to the Diagnosis of RAS (DO NOT EDIT)[1]
| Class I |
| "1.Onset of hypertension before the age of 30 years or severe hypertension after the age of 55. (Level of Evidence: B)" |
| "2.Accelerated, resistant, or malignant hypertension. (Level of Evidence: C)" |
| "3.Development of new azotemia or worsening renal function after administration of an ACE inhibitor or ARB agent . (Level of Evidence: B)" |
| "4.Unexplained atrophic kidney or size discrepancy between kidneys of greater than 1.5 cm. (Level of Evidence: B)" |
| "5.Sudden, unexplained pulmonary edema. (Level of Evidence: B)" |
| Class IIa |
| "1.Unexplained renal dysfunction, including individuals starting renal replacement therapy. (Level of Evidence: B)" |
| Class IIb |
| "1.Multi-vessel coronary artery disease. (Level of Evidence: B)" |
| "2.Unexplained congestive heart failure. (Level of Evidence: C)" |
| "3.Refractory angina. (Level of Evidence: C)" |
Diagnostic Methods (DO NOT EDIT)[1]
| Class I |
| "1. Duplex ultrasonography is recommended as a screening test to establish the diagnosis of RAS. (Level of Evidence: B)" |
| "2. Computed tomographic angiography (in individuals with normal renal function) is recommended as a screening test to establish the diagnosis of RAS. (Level of Evidence: B)" |
| "3. Magnetic resonance angiography is recommended as a screening test to establish the diagnosis of RAS. (Level of Evidence: B)" |
| "4. When the clinical index of suspicion is high and the results of noninvasive tests are inconclusive, catheter angiography is recommended as a diagnostic test to establish the diagnosis of RAS. (Level of Evidence: B)" |
| Class III |
| "1. Captopril renal scintigraphy is not recommended as a screening test to establish the diagnosis of RAS. (Level of Evidence: C)" |
| "2. Selective renal vein renin measurements are not recommended as a useful screening test to establish the diagnosis of RAS. (Level of Evidence: B)" |
| "3. Plasma renin activity is not recommended as a useful screening test to establish the diagnosis of RAS. (Level of Evidence: B)" |
| "4. The captopril test (measurement of plasma renin activity after captopril administration) is not recommended as a useful screening test to establish the diagnosis of RAS. (Level of Evidence: B)" |
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH; et al. (2013). "Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 127 (13): 1425–43. doi:10.1161/CIR.0b013e31828b82aa. PMID 23457117.
- ↑ Lewin A, Blaufox MD, Castle H, Entwisle G, Langford H (1985). "Apparent prevalence of curable hypertension in the Hypertension Detection and Follow-up Program". Arch Intern Med. 145 (3): 424–7. PMID 3872106.
- ↑ Turnbull JM (1995). "The rational clinical examination. Is listening for abdominal bruits useful in the evaluation of hypertension?". JAMA. 274 (16): 1299–301. PMID 7563536.
- ↑ Svetkey LP, Kadir S, Dunnick NR, Smith SR, Dunham CB, Lambert M; et al. (1991). "Similar prevalence of renovascular hypertension in selected blacks and whites". Hypertension. 17 (5): 678–83. PMID 2022411.
- ↑ Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss L; et al. (2013). "Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 61 (14): 1555–70. doi:10.1016/j.jacc.2013.01.004. PMC 4492473. PMID 23473760.