Diagnosis of

Renovascular Hypertension
Cholatip Pongskul

Characteristics of atherosclerotic
and fibromuscular dysplasia
Variable

Atherosclerotic

Fibromuscular
dysplasia

Age at presentation

Older(>50 yr)

Usually young(<40 yr)

Sex

Either

Usually female

Lesion location

Ostial, proximal, middle

Middle or distal

BP response to
revascularization

Unclear

Normotensive in most
patients

Atherosclerotic

Elderly>50

Fibromuscular dysplasia

Younger<40,female
Response to correction

Pathophysiology of renal artery stenosis

Who should be tested for

renovascular hypertension?
45-year-old man, uremia, BP 160/90
mmHg, proteinuria, kidney 8.5, 8 cm
70-year-old man, smoker, hypertension,
dyslipidemia, presented with pulmonary
edema, Cr=1.4 mg/dl
60-year-old woman with pulmonary
edema, BP 180/100 mmHg, Cr=1.2 mg/dl

Who
Should be tested

What test
Should be performed

How
to interpret the result

Who
Onset of severe hypertension after 55
Unexplained deterioration of kidney function
Rising > 50%, 1 week, ACEI

Severe hypertension in diffuse atherosclerosis

Severe hypertension with asymmetry kidney >
1.5 cm
Severe hypertension with flash pulmonary
edema, refractory CHF
Systolic-diastolic bruit at one side

Test or not test?

Medication is effective in renovascular
hypertension
Who will benefit from correction?
Testing associated with potential risk
Correction procedure associated with
morbidity/mortality

Test should be performed

in patient with high likelihood of benefit
from

procedure

High likelihood of benefit from

procedure
Short duration
Failure of medical Rx, in patient with high
likelihood of renovascular hypertension
Intolerance to optimal medical therapy
Progressive renal failure
Suspected fibromuscular dysplasia
Recurrent flash pulmonary edema

Gold
Renal angiography

More than 50% stenosis

Other tests
Duplex sonography
CT angiogram
MRA

Duplex doppler sonography

Peak
200 cm/sec

Functional and anatomical

Peak systolic velocity

Sensitivity 85, specificity 92%
Positive predictive value 84%

Positive test: more informative than negative test

Resistive index
(1-end diastolic velocity)/PSV

Predict outcome after revascularization

Limitation

Time consuming

operator dependent

Obese patient

CT angiography

Excellent sensitivity and specificity

Limitation in distal stenosis (FMD)

Magnetic resonance angiography

MRA
Almost 100% sensitivity!
Nephrogenic systemic
fibrosis?

Functional assessment

Captopril renography: less commonly used

Little predictive value

Not for screening test!

Selecting a diagnostic test

Local availability
Expertise with each technique
Renal insufficiency?

Who

Benefit from
correction

New onset HT>55 yr

Deterioration GFR
Asymmetry kidney
Flash pulmonary edema

Test
Failure medical
FMD?
Progressive renal
failure