[Better understanding of atheromatous ischemic renal vascular disease]

Atheromatous ischaemic renal vascular disease (AIRVD) comprises ischaemic renal disease, atheromatous disease of the large arteries and intra-renal atheromatosis. Cholesterol emboli and lesions of nephroangiosclerosis are often associated, affecting the two kidneys. It is an increasingly common cause of chronic renal failure in an aging population, affecting 12 to 14% of new patients requiring dialysis in the United States. Atheromatous stenoses are very progressive with a risk of renal atrophy; they are a marker of polyvascular disease, often detected during other angiographic investigation. Hypertension secondary to the stenosis, still incorrectly called renovascular hypertension, is, however rare, affecting less than 0.5% of hypertensives. For economic reasons, it is important to select patients who need complementary investigation. In view of the absence of specific signs of the pathology, the "presumptive" diagnosis is based on a range of clinical and biological results, especially in a high risk context. The method of investigation varies from team to team, depending on the availability of equipment, the experience of the operators and the patient himself. Duplex Doppler, spiral angioscan and magnetic resonance angiography are the most pertinent investigations for the management of AIRVD. When the diagnosis of renal artery stenosis has been made, the problem of revascularisation, the objective of which is to preserve or restore the functional nephronic mass, has to be treated to prevent progression to end stage renal failure. Although epidemiological and physiopathological evidence is in favour of revascularisation, only renal salvage procedures are imperative. Apart from these indications, the clinical benefits of revascularisation have not yet been demonstrated. In all cases, the control of associated risk factors is essential to maintain the success of revascularisation and slow down the progression of atheromatous disease.