Renal artery stenosis: medical versus interventional therapy

Reports from recent trials indicate little additional benefit from stent supported revascularization in patients with atherosclerotic renal artery stenosis. These data have been questioned, particularly on the basis of including subjects with modest occlusive disease and reports of clinical benefits to patients with episodic congestive heart failure. Nonetheless, these data have moved the pendulum away from renal revascularization as a primary maneuver to one reserved for refractory hypertension and/or progressive loss of renal function and circulatory congestion. Recent data emphasize the limits of the kidney adaptation to reduced blood flow, the eventual development of widespread renal hypoxia with activation of inflammatory and fibrogenic pathways. Experimental data now support developing adjunctive measures to support angiogenesis and anti-inflammatory renal repair mechanisms, such as those observed with cell-based therapy with mesenchymal stem/stromal cells.