Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

atherosclerotic RAS

1st line – antihypertensive therapy + lifestyle modification

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ONGOING
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atherosclerotic RAS
1st line – 

antihypertensive therapy + lifestyle modification

The majority of patients with RAS have refractory or difficult-to-control hypertension. Thus, first-line treatment in this condition involves BP control to a target of <130/80 mmHg, given the high likelihood of concomitant cardiovascular disease.

Renin-angiotensin blockade with an ACE inhibitor or angiotensin II receptor antagonist is an attractive first-line antihypertensive strategy, as their actions target the mechanism of hypertension in RAS. However, it is recommended that BP, kidney function, and electrolytes be followed closely after initiating therapy.

Patients may require referral to a hypertension consultant (e.g., cardiologist or nephrologist).

Some commonly prescribed antihypertensives are shown below. Doses should be started low and increased according to response.

Lifestyle changes include weight loss, low-salt diet, and smoking cessation.

Primary options

captopril: 12.5 to 25 mg orally three times daily

OR

enalapril: 10-20 mg orally once daily

OR

valsartan: 80-160 mg orally once daily

OR

losartan: 25-100 mg orally once daily

Secondary options

hydrochlorothiazide: 25 mg orally once daily

OR

furosemide: 40 mg orally once daily

OR

atenolol: 50-100 mg orally once daily

OR

amlodipine: 10 mg orally once daily

OR

nifedipine: 30 mg orally (extended-release) once daily

OR

prazosin: 2.5 mg orally once daily

Tertiary options

clonidine: 0.1 mg orally twice daily

OR

hydralazine: 10-50 mg orally four times daily

OR

methyldopa: 250-500 mg orally twice daily

OR

minoxidil: 5-40 mg orally once daily

Plus – statin

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atherosclerotic RAS
Plus – 

statin

Treatment recommended for ALL patients in selected patient group

As atherosclerotic RAS is a type of vascular disease, statins should be considered for all patients.

Although direct evidence is lacking for this recommendation, the high prevalence of concomitant peripheral vascular disease (PVD) and coronary artery disease (CAD) makes this recommendation reasonable. However, there are no published studies evaluating particular statin drugs, doses, or LDL cholesterol targets in this population.

Weak evidence suggests that statins may slow the progression of atherosclerotic RAS.[46][47]

Any statin may be used, with a target LDL cholesterol <1.813 to 2.59 mmol/L (70 to 100 mg/dL).

Baseline and periodic evaluation of liver function tests is recommended.

Primary options

atorvastatin: 10-80 mg orally once daily

OR

fluvastatin: 20-80 mg/day orally (immediate-release) given in 1-2 divided doses

OR

lovastatin: 10-80 mg/day orally (immediate-release) given in 1-2 divided doses

OR

rosuvastatin: 5-40 mg orally once daily

OR

simvastatin: 5-40 mg orally once daily; increased risk of myopathy with 80 mg/day dose

Plus – antiplatelet agent

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ONGOING
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atherosclerotic RAS
Plus – 

antiplatelet agent

Treatment recommended for ALL patients in selected patient group

Aspirin should be considered for all patients with atherosclerotic RAS.[16]

Primary options

aspirin: 75-300 mg orally once daily

2nd line – renal artery stenting + continuation of medical therapy

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atherosclerotic RAS
2nd line – 

renal artery stenting + continuation of medical therapy

There are no data supporting routine renal artery stenting in asymptomatic patients in whom RAS is incidentally found.[2]

Renal percutaneous vascular intervention appears to be no better than maximal optimal medical therapy.[45] However, in selected cases, guidelines suggest that renal artery stenting be considered in the following circumstances: refractory hypertension on a multi-drug regimen (≥3 medications); progressive chronic kidney disease; acute kidney injury on ACE inhibitors/angiotensin-II receptor antagonists in patients with congestive heart failure (CHF); recurrent flash pulmonary oedema; bilateral RAS; stenosis of renal artery supplying single functioning kidney; salvage therapy in recent-onset end-stage renal failure; patients with RAS, uncontrolled hypertension, and unstable angina.[3][19][44]

Patient factors that may suggest clinical benefit of revascularisation include a recent onset or exacerbation of hypertension (<1 year), absence of proteinuria, and identifiable activation of the renin-angiotensin system (e.g., hyperreninaemia).[44][Figure caption and citation for the preceding image starts]: Digital subtraction angiography in a patient with significant atherosclerotic left renal artery stenosis. Panel A, prior to stent placement. Panel B, after successful stent deployment. Arrows indicate the site of stenosis and stent placement in their respective panelsCourtesy of Alvaro Alonso, MD and Scott J. Gilbert, MD [Citation ends].com.bmj.content.model.Caption@206eb61c

Patients should be referred to a peripheral vascular interventions specialist if revascularisation is considered. Current medical therapy should be continued and maximised. Transient addition of clopidogrel should be considered for dual antiplatelet therapy after the procedure.

Plus – post-stent clopidogrel

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ONGOING
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atherosclerotic RAS
Plus – 

post-stent clopidogrel

Treatment recommended for ALL patients in selected patient group

Patients undergoing renal artery stenting require dual antiplatelet therapy for a period of time as determined by the vascular specialist.

Patients should continue aspirin, with the addition of clopidogrel after the procedure.

Primary options

clopidogrel: 75 mg orally once daily

3rd line – surgical reconstruction of the renal arteries

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atherosclerotic RAS
3rd line – 

surgical reconstruction of the renal arteries

Surgical reconstruction of the renal arteries in the setting of RAS is restricted to those patients undergoing major aortic reconstruction for another reason, such as abdominal aortic aneurysm (AAA) repair or correction of severe aorto-iliac occlusive disease.[16]

fibromuscular dysplasia

1st line – antihypertensive therapy + lifestyle modification

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ONGOING
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fibromuscular dysplasia
1st line – 

antihypertensive therapy + lifestyle modification

The majority of patients with fibromuscular dysplasia have refractory or difficult-to-control hypertension. Thus, first-line treatment in this condition involves BP control to a target of <140/90 mmHg. More aggressive BP control to <130/80 mmHg is indicated in the presence of concomitant cardiovascular disease.

Although no data support the use of a single agent or combination of drugs over another in fibromuscular dysplasia, the presence of compelling indication in comorbid conditions make antihypertensive selection important.

Furthermore, combination therapy with multiple agents is often necessary.

Renin-angiotensin blockade with an ACE inhibitor or angiotensin II receptor antagonist is an attractive first-line antihypertensive strategy, as their action targets the mechanism of hypertension in RAS. However, it is recommended that BP, kidney function, and electrolytes be followed closely after initiating therapy.

Patients may require referral to a hypertension consultant (e.g., cardiologist or nephrologist).

Some commonly prescribed antihypertensives are shown below. Doses should be started low and increased according to response.

Lifestyle changes include weight loss, low-salt diet, and smoking cessation.

Primary options

captopril: 12.5 to 25 mg orally three times daily

OR

enalapril: 10-20 mg orally once daily

OR

valsartan: 80-160 mg orally once daily

OR

losartan: 25-100 mg orally once daily

Secondary options

hydrochlorothiazide: 25 mg orally once daily

OR

furosemide: 40 mg orally once daily

OR

atenolol: 50-100 mg orally once daily

OR

amlodipine: 10 mg orally once daily

OR

nifedipine: 30 mg orally (extended-release) once daily

OR

prazosin: 2.5 mg orally once daily

Tertiary options

clonidine: 0.1 mg orally twice daily

OR

hydralazine: 10-50 mg orally four times daily

OR

methyldopa: 250-500 mg orally twice daily

OR

minoxidil: 5-40 mg orally once daily

Plus – percutaneous renal artery balloon angioplasty

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fibromuscular dysplasia
Plus – 

percutaneous renal artery balloon angioplasty

Treatment recommended for ALL patients in selected patient group

Angioplasty, together with antihypertensive therapy, should be considered first-line therapy, as it is often curative. Angioplasty has an initial technical success rate and 10-year patency rate of approximately 90%.[49]

Consider – renal artery stenting and dual antiplatelet therapy

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ONGOING
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fibromuscular dysplasia
Consider – 

renal artery stenting and dual antiplatelet therapy

Additional treatment recommended for SOME patients in selected patient group

Stenting is not indicated for initial treatment of fibromuscular dysplasia except in cases of procedural complications during percutaneous renal artery balloon angioplasty (i.e., renal artery dissection). It could be considered in the setting of re-stenosis.[16]

Patients undergoing renal artery stenting require dual antiplatelet therapy (with aspirin and clopidogrel) following the procedure.

Primary options

aspirin: 75-300 mg orally once daily

and

clopidogrel: 75 mg orally once daily

2nd line – surgical reconstruction of the renal arteries

Back
ONGOING
|
fibromuscular dysplasia
2nd line – 

surgical reconstruction of the renal arteries

Surgical reconstruction of the renal arteries in the setting of fibromuscular dysplasia is restricted to those patients undergoing major aortic reconstruction for another reason. Surgical intervention may be necessary in complex disease that extends into the segmental arteries, and in cases of macroaneurysms.[16]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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