michigan hypertension core curriculum - State of Michigan

generally have renovascular hypertension, ACEI and ARB are usually effective. Patients who do not
respond or develop vital organ injury should be considered for revascularization. Clinical follow up
is recommended; uncontrolled hypertension or new vital organ injury should prompt repeat invasive
evaluation.
Approach to unilateral ARAS. In patients with controlled-hypertension and no vital organ injury, we
recommend assessment for nephropathy (Table 5) and renal ischemia (Table 6), before considering
revascularization. If these studies demonstrate normal kidneys and no renal ischemia (Type 1A), we
recommend antihypertensive therapy (including ACEI or ARB), smoking cessation, exercise, weight
reduction, optimal management of hyperglycemia and hypercholesterolemia, and aspirin.
If studies demonstrate normal kidneys and renal ischemia (Type 1B), we consider this a
manifestation of “unilateral” vital organ injury, and such patients could be considered for renal stenting.
The physician may be confronted by a more challenging decision in patients with serum creatinine > 2
mg/dL and unilateral ARAS. In these patients, nephropathy is highly likely (Type 2), and preservation of
renal function is less likely after revascularization. If such patients develop cardiovascular injury, renal
revascularization may be reasonable if renal ischemia is present (Type 2B), although renal function
may not improve; recommendations in these patients should be individualized.
Approach to bilateral ARAS or ARAS of a solitary kidney. Patients with bilateral ARAS or ARAS
of a solitary kidney may have global severe renal ischemia, and are more prone to pulmonary edema
than those with unilateral RAS. When a diagnosis of bilateral ARAS is made, the nature of the clinical
evaluation is similar to the one described for unilateral ARAS, and includes a thorough assessment for
nephropathy (Table 5) and renal ischemia (Table 6). The presence of advanced nephropathy (Type 2)
is a predictor of poor recovery of renal function after revascularization, particularly if renal ischemia is
absent (Type 2A). Although there may be benefit for preventing recurrent pulmonary edema if renal
ischemia is suggested by noninvasive or invasive evaluation (Type 2B), renal function may not improve.
Patients with severe bilateral ARAS, minimal or no nephropathy, renal ischemia (Type 1B),
and cardiovascular injury are ideal candidates for renal revascularization. Evidence for nephropathy
may be missed if Scr is the only measure of renal function. Such patients should be considered for
revascularization if nuclear GFR is < 60 cc/min/1.73 m2, even in the absence of cardiac or cerebral
dysfunction, before the development of more advanced renal dysfunction. Nuclear blood flow studies
and/or invasive assessment of ischemia are useful in patients with bilateral ARAS to identify the more
NKFM & MDCH 117