Renal artery stenosis and ischaemic nephropathy — Rapid

Synopsis

Recognise clinically important renovascular disease, investigate it proportionately and separate patients needing cardiovascular risk treatment from the small high-risk group who may benefit from revascularisation.

Most renal-artery stenosis in older adults is ostial atherosclerotic disease; fibromuscular dysplasia more often affects younger women and the mid-to-distal artery, and is considered separately.
Suspect a renovascular contribution when hypertension is genuinely resistant, starts abruptly or worsens unexpectedly, accompanies an abdominal bruit, or coexists with asymmetrical kidney size, widespread atherosclerosis or otherwise unexplained kidney decline.
A creatinine rise of 30% or more, or eGFR fall of 25% or more, after starting or increasing an ACE inhibitor or ARB should prompt repeat testing and a search for depletion, NSAIDs and renovascular disease rather than an automatic lifelong drug-allergy label.

Key red flags

RAAS-blockade signal

Kidney function deteriorates substantially soon after ACE-inhibitor or ARB initiation or dose escalation, particularly with little albuminuria, no obvious hypovolaemia and bilateral disease or a solitary kidney on imaging.

Investigation priorities

Standardised clinic and out-of-office blood pressureFirst step

Confirm severity and distinguish sustained resistance from technique, adherence or white-coat effects.

Management branches

Flash oedemaStabilise and expose the renovascular phenotype

Abrupt pulmonary oedema with severe hypertension, acute kidney injury or recurrent unexplained episodes.

Treat oxygenation, ventilation, blood pressure and congestion through the acute heart-failure pathway, obtain ECG and urgent biochemistry, and avoid an indiscriminate fluid challenge.
Review prior kidney function, RAAS-blocker exposure and cardiac imaging; request urgent renal-artery imaging if bilateral disease or a solitary functioning kidney is plausible.

Stable suspicionConfirm before imaging

Difficult hypertension, progressive CKD, a bruit or asymmetric kidneys without acute organ injury.

Key medicines

ACE inhibitor or angiotensin-receptor blockerChoose and titrate a licensed preparation to the highest tolerated dose under the indication-specific formulary.

Amlodipine and complementary antihypertensivesAmlodipine commonly starts at 5 mg once daily, then is titrated within its licence; combine according to NICE sequencing.

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