Approach to the Patient with Chronic Kidney Disease and Renovascular Disease

Renovascular disease results most commonly from atherosclerotic vascular occlusion. Although clinically significant loss of GFR is characteristic of its more severe forms, renovascular disease is often complicated by widespread cardiovascular manifestations and pre-existing microvascular injury, making management of these patients challenging. The kidney tolerates moderate reductions of blood flow and oxygenation, but severe arterial occlusion eventually leads to loss of kidney function. Recent studies demonstrate pro-inflammatory changes in the renal vasculature preceding kidney injury, which are followed by rarefaction of the renal microvasculature. Tissue inflammation and fibrosis ensue and eventually reach a point of irreversible structural injury that precludes recovery of glomerular filtration. Medical treatment of hypertension, comorbidities, anemia and electrolyte disorders is the cornerstone of management for 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 novel adjunctive measures, including cell-based therapies, may attenuate injury or facilitate renal repair mechanisms for more effective recovery of kidney function.