Approach to the Patient with Chronic Kidney Disease and Renovascular Disease

Renovascular disease (RVD) results most commonly from atherosclerotic vascular occlusion. Although clinically significant loss of glomerular filtration rate develops with its more severe forms, RVD is often complicated by widespread cardiovascular manifestations and preexisting microvascular injury, making management of these patients challenging. The kidney adapts to moderate reductions of blood flow and oxygenation, but severe arterial occlusion eventually leads to tissue hypoxia and loss of kidney function. Recent studies demonstrate proinflammatory changes in the renal vasculature preceding kidney injury, which are followed by rarefication of renal microvessels. Tissue inflammation and fibrosis ensue and eventually produce irreversible structural injury that precludes recovery of glomerular filtration. Medical treatment of hypertension, comorbidities, anemia, and electrolyte disorders is fundamental to the management of these patients. Renal revascularization is beneficial for selected patients with progressive decline in kidney function, refractory hypertension, and/or recurrent circulatory congestion or pulmonary edema. Experimental studies indicate that evolving adjunctive measures, including cell-based therapy and mitochondrial protection, may attenuate injury or facilitate renal repair mechanisms for preservation of kidney function.