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 Basic Science of Renovascular Hypertension

1. Anatomy of the renal vasculature

  • Arterial anatomy.
  • Venous anatomy.

2. Physiology of the renin-angiotensin system

  • Angiotensin peptides and the nephron.
  • Angiotensin peptides and the cardiovascular system.
  • Angiotensin peptides and the central nervous system.
  • Angiotensin peptides and the adrenals.

3. Mechanisms of renal autoregulation

  • The myogenic mechanism and angiotensin peptides.
  • Tubuloglomerular feedback and angiotensin peptides.
  • Vascular endothelial substances.
  • Renal nerves and function regulation.

4. Pathologic considerations

  • Atherosclerosis (etiology, pathology, pathophysiology).
  • Fibromuscular dysplasia (etiology, pathology, pathophysiology).
  • Developmental lesions (etiology, pathology).

5. Diagnostic studies (performance, diagnostic criteria, application and limitations, accuracy)

  • Screening studies for renovascular occlusive disease (rapid sequence excretory pyelogram, peripheral plasma renin assays, renal Duplex ultrasonography, renal arteriography).
  • Functional studies (isotope renography, renal vein renin assays, split renal function studies).

References

Welch WJ. The pathophysiology of renin release in renovascular hypertension. Semin Nephrol 2000;20:394-401.

This article reviews the pathophysiology of renin release in renovascular hypertension, including stimuli and mechanisms of release as well as factors modifying renin release.

Palmer BF. Impaired renal autoregulation: implications for the genesis of hypertension and hypertension-induced renal injury. Am J Med Sci 2001;321:388-400.

Autoregulation of the renal vasculature provides a mechanism by which renal function is maintained relatively constant despite variations in systemic blood pressure. Alterations in the autoregulatory response can have clinical consequences such as hypertension, hypertension-induced renal injury and increase in the serum creatinine concentration. The consequences of impaired renal autoregulation are discussed in this review.

Begelman SM, Olin JW. Fibromuscular dysplasia. Curr Opin Rheumatol 2000;12:41-47.

Fibromuscular dysplasia is an important cause of renovascular hypertension in young, predominantly female patients. This article presents the main characteristics of fibromuscular dysplasia, including pathologic classification, etiology, clinical manifestations, differential diagnosis and treatment.

Mitty HA, Shapiro RS, Parsons RB, Silberzweig JE. Renovascular hypertension. Radiol Clin North Am 1996;34:1017-1036.

This paper presents diagnostic imaging modalities of renovascular hypertension including captopril scintigraphy, angiography, Doppler sonography and MR angiography. The indications, advantages and disadvantages of each technique are discuused.

Bloch MJ. An evidence-based approach to diagnosing renovascular hypertension. Curr Cardiol Rep 2001;3:477-484.

Available tests for the diagnosis of renovascular hypertension can be divided into those that identify the functional consequences of a renal artery obstruction (angiotensin-converting enzyme inhibitor-augmented renography) and those that identify the anatomic presence of stenosis (duplex ultrasonography, magnetic resonance angiography, and contrast tomography angiography). After reviewing current evidence regarding the use of these techniques, the authors present a potential treatment algorithm.

Posted June 2010