Ischemic nephropathy: more than a simple renal artery narrowing

Renal artery stenosis in elderly patients is mainly caused by atherosclerosis. The prevalence of this disorder in patients with chronic kidney diseases is reported to be 0.5% to 5.5%. However, because the patients with atherosclerotic renal artery disease are mostly asymptomatic, the true prevalence is expected to be higher. Renovascular hypertension and ischemic nephropathy are two main consequences of this disease, but it is difficult to determine in which patient the progress of stenosis may cause these syndromes. The big challenge in renal artery stenosis is how to manage the patients. In the past 70 years, it has been believed that simply maintaining of kidney perfusion by opening the stenosis could control blood pressure and preserve kidney function. Nowadays, the blood pressure can be controlled well by medical treatment without the need for revascularization; however, management of ischemic nephropathy remains a dilemma. With advancements in understanding the pathophysiology of changes in the parenchyma of the kidney after stenosis, it is now generally accepted that only a minority of patients with ischemic nephropathy will benefit from revascularization. Nonetheless, finding these patients is critical and need more randomized trials to show who mostly benefit from revascularization and when it may save the kidney.