Bosmans J L, De Broe M E
Department of Nephrology and Hypertension, University Hospital Antwerp, Belgium.
JBR-BTR. 2004 Jan-Feb;87(1):32-5.
Atherosclerotic renal artery stenosis (ARAS) is associated with two common clinical syndromes: renovascular hypertension and ischemic nephropathy, which often coexist. The ensuing renovascular disease constitutes the fastest-growing etiology of end-stage renal disease. Diagnostic work-up for hemodynamical significant renal artery stenosis should be restricted to patients suspected to be at moderate or high risk for renovascular disease. Patients at moderate risk should first undergo a screening test, like Doppler ultrasonography or captopril-enhanced scintigraphy. In case of a positive screening test, renal artery imaging with either spiral computed tomography angiography or magnetic resonance angiography with Gadolinium is indicated. Patients at high risk for renovascular disease may be directly referred for intra-arterial renal artery angiography, the golden standard diagnostic procedure. A renal artery stenosis with narrowing of > 50-60% of the lumen, is considered hemodynamically significant, and may be suitable for treatment with angioplasty or angioplasty plus stent placement (in case of osteal renal artery stenosis). The therapeutic approach of the hypertensive patient with a hemodynamically significant renal artery stenosis is currently a matter of great debate. In any case optimal medical therapy with antihypertensive, lipid-lowering, and platelet-inhibiting drugs should be instituted, since such approach may not only prevent the progression to end-stage renal disease, but may also prevent the progression of extra-renal vascular disease, which affects the majority of these patients. Current evidence suggests that angioplasty (with additional stent placement in case of osteal renal artery stenosis) may benefit a subset of patients with significant RAS, i.e. patients with a resistance index < 80% at the level of the segmental renal arteries, and patients with bilateral RAS or patients with unilateral RAS with a unique functioning kidney. Prospective, randomized and controlled studies with clearly defined clinical endpoints are needed to better define the absolute and relative indications of angioplasty (plus stenting) in the setting of renal artery stenosis.
动脉粥样硬化性肾动脉狭窄（ARAS）与两种常见临床综合征相关：肾血管性高血压和缺血性肾病，二者常并存。随之而来的肾血管疾病是终末期肾病中增长最快的病因。对于血流动力学上有显著意义的肾动脉狭窄的诊断性检查应仅限于怀疑有中度或高度肾血管疾病风险的患者。中度风险患者应首先进行筛查试验，如多普勒超声检查或卡托普利增强闪烁扫描。如果筛查试验呈阳性，则需进行螺旋计算机断层血管造影或钆增强磁共振血管造影的肾动脉成像。肾血管疾病高风险患者可直接转诊进行动脉内肾动脉血管造影，这是诊断的金标准程序。管腔狭窄>50 - 60%的肾动脉狭窄被认为在血流动力学上具有显著意义，可能适合进行血管成形术或血管成形术加支架置入术（如肾动脉骨部狭窄的情况）。对于有血流动力学显著意义的肾动脉狭窄的高血压患者，其治疗方法目前存在很大争议。无论如何，都应采用抗高血压、降脂和抗血小板药物进行最佳药物治疗，因为这种方法不仅可以预防进展至终末期肾病，还可以预防影响这些患者大多数的肾外血管疾病的进展。目前的证据表明，血管成形术（如肾动脉骨部狭窄则额外置入支架）可能使一部分有显著肾动脉狭窄（RAS）的患者受益，即肾段动脉水平阻力指数<80%的患者、双侧RAS患者或单侧RAS且仅有一个功能肾的患者。需要进行具有明确界定临床终点的前瞻性、随机对照研究，以更好地确定在肾动脉狭窄情况下血管成形术（加支架置入）的绝对和相对适应证。
