Hypertensive and ischemic nephropaties, renovascular diseases

1. Zehra Eren, M.D. Hypertensive and ischemic nephropaties, renovascular diseases

2. LEARNING OBJECTIVES • explain hypertansion and renal disease interaction, • describe renovascular diseases • describe diagnostic evaluation • explan therapy in renovascular deseases • describe and manage renal artery and vein thrombosis • explain microvascular renal diseases

3. Hypertensionandrenaldisease

5. Clinical manifestations of renovascular disease • Asemptomatic ‘’İncidental Renal Artery Stenosis’’ • Renovascular Hypertension • İschemic Nephropathy • Accelerated CV Disease -Congestive heart failure -Stroke -Secondary aldosteronism

6. Clinicalmanifestations of renovasculardisease • Asemptomatic ‘’İncidental Renal Artery Stenosis (RAS)’’ • Renovascular Hypertension • İschemic Nephropathy • Accelerated CV Disease -Congestive heart failure -Stroke -Secondary aldosteronism

7. Asemptomatic ‘’İncidentalRenalArteryStenosis’’ • Some degree of RAS can be identified in 20%-45% of patients undergoing vascular imaging • Most of these stenoses are of little or no hemodynamic significance

8. Clinical manifestations of renovascular disease • Asemptomatic ‘’İncidental Renal Artery Stenosis (RAS)’’ • Renovascular Hypertension • İschemic Nephropathy • Accelerated CV Disease -Congestive heart failure -Stroke -Secondary aldosteronism

9. Pathogenesis

10. RenovascularHypertension • Reducedrenalperfusion Rise in arterialpressure • Diagnosis is establishedonly in retrospectaftersuccesfulreversal of HT withrevascularization

11. Lesionsproducingrenovascularhypertension

12. FibromuscularDisease • 3%-5%, F>M • Medial fibroplasia is the most common • Location: midportion of the vessel • Smoking is a risk factor for progression

13. FMD

14. Atherosclerosis • Mostcommonrenovascularlesion (75% - 84%) • Location: origin of artery • Associatedwith HT, DM, HPL, smoking, abnormalrenalfunction

16. Bilateral RAS

19. Changes of renin-angiotensinsystem in renovascularhypertension

22. Clinicalfeatures

23. Clinicalsyndromes

24. Diseaseprogression in atheroscleroticrenalarterystenosis

25. Clinicalmanifestations of renovasculardisease • Asemptomatic ‘’İncidentalRenalArteryStenosis’’ • RenovascularHypertension • İschemicNephropathy • Accelerated CV Disease -Congestiveheartfailure -Stroke -Secondaryaldosteronism

26. Pathophysiology of ischemicrenaldisease

28. Goals of Diagnostic Evaluation • Establish presence of RAS: location and type of lesion • Establish whether unilateral or bilateral stenosis (or stenosis to a solitary kidney) • Establish presence and function of stenotic and nonstenotic kidneys • Establish hemodynamic severity of renal arteral disease • Plan vascular intervention

29. DiagnosticTestingforRenovascularHypertensionandİschemicNephropathyDiagnosticTestingforRenovascularHypertensionandİschemicNephropathy • Physiologic and functional studies of the Renin-Angiotensin system -plasma renin levels -measurement of renal vein renin levels • Noninvasive imaging and assesment of the renal vasculature -Doppler USG -radyonuclide imaging -magnetic resonance arteriography -computed tomographic angiography

31. Dopplerultrasonography

33. Gadolinium-enhancedmagneticresonance (MR) angiography

34. Computed tomography angiogram

35. Angiography

37. Goals of Therapy • Improved BP • Prevent morbidity and mortality • Preservation of renal function

38. Therapy • Medical therapy • Surgical therapy -angioplasty -angioplasty and stent replacement

40. Serum creatinineandbloodpressurelevelsbeforeandafterpercutaneousrenalarteryangioplasty (PTRA)

41. Clinical Factors Favoring Medical Therapy and Revascularization or Surveillance for Renal Artery Stenosis

42. Disorders of RenalArteriesandVeins

43. Causes of renalarterythrombosis

44. Symptoms of renalarteryocclusion

45. Peripheralmanifestations of atheroembolicdisease

46. Acutefocalinfarct

47. Occlusion of theleft main renalarteryby a metastaticdeposit

48. Successfulembolization of a largerightrenalarteryaneurysm

49. Segmentalrenalarteryocclusions

50. Segmentalrenalarteryocclusions