Which antihypertensive agents are used to control BP in patients with renal artery stenosis
Does it matter which antihypertensive agents are used to control blood pressure in patients with renal artery stenosis?
As long as inhibitors of the renin-angiotensin system (RAS) do not precipitate kidney failure, patients with atherosclerotic renal artery stenosis treated with ACE inhibitors seem to have more favorable long-term outcomes compared with those not taking ACE inhibitors.
Consequently, this class of medications is preferred in the treatment of hypertension associated with atherosclerotic renal artery stenosis. Moreover, as long as severe bilateral disease is not present, antagonists of the RAS would not necessarily be expected to precipitate acute kidney failure. A rise in serum creatinine of up to 30% from baseline after initiation of an ACE inhibitor or ARB is often observed, particularly in patients with some underlying chronic kidney disease, and should not prompt discontinuation of the medication. In contrast, a more substantial decline in kidney function (creatinine increase of >30%) or significant hyperkalemia (potassium >6) after initiation of a RAS inhibitor should raise some suspicion for concurrent states of decreased effective arterial blood volume such as volume depletion or decompensated heart failure, nonsteroidal antiinflammatory drug use, bilateral renal artery stenosis, or renal artery stenosis of a solitary kidney. In this situation the RAS inhibitor should be at least temporarily held and these possibilities explored.
