Version July 2025
ACE: angiotensin-converting enzyme; ARB: angiotensin II receptor blocker; BP: blood pressure; CT: computed tomography; eGFR: estimated glomerular filtration rate; MR: magnetic resonance; RAS inhibitor: renin-angiotensin system inhibitor.
* In patients with atherosclerotic disease, an intensive BP goal is appropriate if the patient has confirmed atherosclerotic renal artery stenosis, as in other patients at high cardiovascular risk. An RAS inhibitor (ie, ACE inhibitor or ARB) should be part of the antihypertensive drug regimen in such patients since they tend to be more effective in lowering the BP compared with other agents in the setting of renovascular disease and because they are associated with reduced cardiovascular risk in this population. However, RAS inhibitors may worsen kidney function in patients with renal artery stenosis. In general, the RAS inhibitor can be continued if the eGFR declines by less than 30 to 40% and does not continue to worsen, and if the patient's BP is not lowered excessively (eg, systolic pressure <110 mmHg).
¶ If the patient has confirmed atherosclerotic renal artery stenosis or evidence of existing atherosclerotic disease in other vascular beds, they should be treated for secondary prevention of cardiovascular disease. Refer to UpToDate topic on lipid lowering for secondary prevention for details.
Δ Options for noninvasive imaging include CT angiography, MR angiography, or Doppler ultrasound. Refer to UpToDate content on diagnosing renal artery stenosis for details.
◊ Typically defined as a stenosis >70%.
§ Patients who do not have severe renal artery stenosis to explain their symptoms and signs (eg, true resistant hypertension, unexplained kidney function decline) generally require specialist referral for evaluation and treatment.
¥ Apparent resistant hypertension with uncontrolled BP is defined as uncontrolled BP despite prescription of three or more antihypertensive agents at moderate to high doses, including a diuretic. Among patients with apparent resistant hypertension, the diagnosis of true resistant hypertension requires confirmation of adherence to antihypertensive drug therapy and confirmation of poor BP control by out-of-office readings (eg, ambulatory blood pressure monitoring or self-measured blood pressure).
‡ When revascularization is indicated, endovascular stenting is usually appropriate. However, surgical revascularization may be warranted in patients with: multiple small renal arteries or multiple prior failed stent procedures; early primary branching of the main renal artery; requirement for aortic reconstruction near the renal arteries for other indications; or if it is necessary to avoid manipulation of a highly diseased aorta or failed endovascular stent.
