Renovascular hypertension: is there still a role for stent revascularization?

Management of renovascular hypertension remains controversial and problematic, in part, due to failure of prospective trials to demonstrate added benefit to revascularization.

Effective drug therapy often can achieve satisfactory blood pressure control, although concerns persist of the potential for progressive, delayed loss of kidney function beyond a stenotic lesion. Recent studies highlight benefits of renal artery stenting in subsets of patients including those with recurrent pulmonary edema and those intolerant to blockade of the renin-angiotensin system. Occasional patients with recent deterioration in renal function recover sufficient glomerular filtration rate after stenting to avoid requirements for renal replacement therapy. Emerging paradigms from both clinical and experimental studies suggest that hypoxic injury within the kidney activates inflammatory injury pathways and microvascular rarification that may not recover after technically successful revascularization alone. Initial data suggest that additional measures to repair the kidney, including the use of cell-based therapy, may offer the potential to recover kidney function in advanced renovascular disease.

Specific patient groups benefit from renal revascularization. Nephrologists will increasingly be asked to manage complex renovascular patients, different from those in randomized trials, that require intensely individualized management.