[Atherosclerosis and the kidney]

Area of Science:

• Cardiovascular Medicine
• Nephrology
• Vascular Surgery

Context:

• Diffuse atherosclerosis frequently involves renal arteries, posing a significant risk for atherosclerotic renal artery stenosis (ARAS).
• Renal artery stenosis can lead to ischemia, activating the renin-angiotensin-aldosterone system and potentially compromising renal function under antihypertensive treatment.
• Clinical suspicion for ARAS is raised by renal asymmetry, flash pulmonary edemas, and characteristic findings on imaging studies like ultrasonography and CT angiography.

Purpose:

• To review the diagnostic modalities for ARAS, including imaging techniques and noninvasive methods like pulsed echo-doppler.
• To discuss the indications and outcomes of revascularization procedures for ARAS, emphasizing the benefit-risk assessment.
• To highlight the occurrence and diagnostic challenges of renal cholesterol crystal embolism (CCE) as a complication of atherosclerotic disease and interventions.

Summary:

• Pulsed echo-doppler is the preferred noninvasive method for evaluating ARAS, assessing stenosis progression, and predicting functional improvement after revascularization based on the resistance index.
• Renal arteriography, while carrying risks like cholesterol crystal embolism, is essential for angioplasty and stent placement in non-atrophic kidneys.
• Renal cholesterol crystal embolism (CCE) presents as a severe condition mimicking vasculitis, diagnosed through clinical, laboratory, and biopsy findings, with recent treatments showing improved outcomes.

Impact:

• Accurate diagnosis and appropriate management of ARAS can potentially preserve renal function and reduce cardiovascular morbidity.
• Understanding the risks associated with interventions and the natural history of ARAS is vital for patient management.
• Recognition and timely treatment of CCE can significantly improve prognosis in patients with atherosclerotic disease.