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Atherosclerotic-nephropathy: an updated narrative review
Mariadelina Simeoni1, Silvio Borrelli2, Carlo Garofalo3
1Nephrology Units at University "Magna Graecia", Catanzaro, Italy.
Insights
Atherosclerotic nephropathy, common in elderly patients, stems from atherosclerosis and hypertension. While revascularization has limited renal benefits, lifestyle changes and medications slow disease progression, with emerging anti-fibrotic therapies showing promise.
Area of Science:
- Nephrology
- Cardiovascular Medicine
- Geriatrics
Background:
- Chronic kidney disease (CKD) is increasingly prevalent in elderly individuals, primarily driven by long-term atherosclerosis and hypertension.
- Atherosclerotic renal vascular disease (ARVD) and hypertensive nephropathy contribute to CKD through ischemia, inflammation, fibrosis, and vascular remodeling.
- Distinguishing between these conditions in elderly patients can be challenging, leading to the concept of atherosclerotic nephropathy.
Purpose of the Study:
- To review the mechanisms, diagnosis, and management of atherosclerotic nephropathy in elderly patients.
- To discuss the role of novel diagnostic tools and therapeutic interventions in managing CKD related to atherosclerosis and hypertension.
Main Methods:
- Literature review of studies on chronic kidney disease, atherosclerosis, hypertension, and renal vascular disease.
- Analysis of diagnostic advancements including intravascular ultrasound and BOLD-MRI.
- Evaluation of therapeutic strategies, including revascularization, lifestyle modifications, pharmacotherapy, and emerging anti-fibrotic agents.
Main Results:
- Atherosclerotic nephropathy is a complex syndrome resulting from the interplay of ischemic and hypertensive damage to the kidneys.
- Novel imaging techniques aid in identifying renal lesions amenable to intervention.
- Renal revascularization shows limited benefit for renal outcomes but may help avoid dialysis and manage blood pressure in select patients.
- Lifestyle changes, statins, antiplatelets, and careful use of renin-angiotensin system inhibitors are key to slowing disease progression.
Conclusions:
- Atherosclerotic nephropathy is a significant clinical syndrome in the elderly, necessitating a comprehensive management approach.
- While revascularization has a limited role, conservative management and targeted therapies are crucial for slowing CKD progression.
- Emerging anti-fibrotic therapies targeting mesenchymal stem cells and micro-RNA offer future potential for treating ARVD, pending further research on safety and efficacy.
Abstract:
The increased prevalence of chronic kidney disease (CKD) in elderly patients recognizes, as main cause, the long-term exposure to atherosclerosis and hypertension. Chronic ischemic damage due to critical renal arterial stenosis induces oxidative stress and intra-renal inflammation, resulting in fibrosis and microvascular remodelling, that is the histological picture of atherosclerotic renal vascular disease (ARVD). The concomitant presence of a long history of hypertension may generate intimal thickening and luminal narrowing of renal arteries and arterioles, glomerulosclerosis, interstitial fibrosis and tubular atrophy, more typically expression of hypertensive nephropathy. These complex mechanisms contribute to the development of CKD and the progression to End Stage Kidney Disease. In elderly CKD patients, the distinction among these nephropathies may be problematic; therefore, ischemic and hypertensive nephropathies can be joined in a unique clinical syndrome defined as atherosclerotic nephropathy. The availability of novel diagnostic procedures, such as intra-vascular ultrasound and BOLD-MRI, in addition to traditional imaging, have opened new scenarios, because these tools allow to identify ischemic lesions responsive to renal revascularization. Indeed, although trials have deflated the role of renal revascularization on the renal outcomes, it should be still used to avoid dialysis initiation and/or to reduce blood pressure in selected elderly patients at high risk. Nonetheless, lifestyle modifications (smoking cessation, increased physical activity), statins and antiplatelet use, as well as cautious use of renin-angiotensin system inhibitors, remain the main therapeutic approach aimed at slowing the renal damage progression. Mesenchymal stem cells and Micro-RNA are promising target of anti-fibrotic therapy, which might provide potential benefit in ARVD patients, though safety and efficacy profile in humans is unknown too.
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