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Kidney non-tumor

Blood vessel disorders

Renal artery stenosis

Reviewers: Nikhil Sangle, M.D. (see Reviewers page)
Revised: 26 December 2012, last major update August 2012
Copyright: (c) 2003-2012, PathologyOutlines.com, Inc.

General
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● Hypertension that responds to ACE inhibitors, with stenosis by intravenous pyelogram or renal scans, bruit, elevated renin
● 2-5% of cases of hypertension, surgery curative in 70%

Causes
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● Atheromatous plaque: more common in older men with diabetes, often at orifice of renal artery and associated with aneurysmal dilatation of aorta distal to renal arteries
● Fibromuscular dysplasia: more common in younger women; may involve other vessels; not responsive to hypertensive drugs; 50% bilateral, often involve distal 2/3 of renal artery; due to intimal, medial, perimedial or periarterial fibroplasia, medial hyperplasia or medial dissection
● Radiation injury: loss of muscle, intense fibrosis in all wall layers; usually after radiation treatment, including renal artery field years previous
● Takayasu’s aortitis: also called pulseless disease; chronic sclerosing aortitis of unknown etiology

Case reports
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● 4 year old boy with segmental renal artery stenosis (Am J Surg Pathol 1994;18:512)
● 35 year old woman with aortic coarctation and renal artery stenosis due to fibromuscular dysplasia (Arch Pathol Lab Med 1989;113:809)
● Due to misplaced surgical clips post-nephrectomy (BMJ Case Rep 2012 Aug 13)

Treatment
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● Anti-hypertensive medications
● Angioplasty with stent placement may be effective, even in transplanted kidney (Nefrologia 2012;32:455)
● Revascularization is usually not effective for atherosclerotic renovascular disease (Nephrol Dial Transplant 2012;27:3843, Cardiol Rev 2012;20:189)

Gross description
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● Shrunken kidney

Gross images
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Renal artery stenosis with atrophic kidney

Micro description
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● Diffuse atrophy with crowded and smaller glomeruli, atrophic tubules and interstitial fibrosis (Lab Invest 1991;65:558)
● Arterioles usually normal
● Usually no hypertensive changes in small vessels, although opposite kidney may show hypertensive changes
● Medial fibroplasia: multiple foci of stenosis alternate with microaneurysms to produce “string of beads”
● Perimedial fibroplasia: normal outer half of media but hyperplasia of muscle causes uniform circumferential thickening of vessel wall with luminal narrowing
● Intimal fibroplasia: hyperplasia of intima, resembling atherosclerosis, but without lipid deposition
● Periarterial fibroplasia: rare, fibrosis of adventitia extends into adjacent adipose and connective tissue, causing constriction from without

Micro images
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Patient with central renal artery stenosis and persistent allograft dysfunction shows focal acute tubular injury and intratubular proteinaceous cast material (asterisk)

End of Kidney non-tumor > Blood vessel disorders > Renal artery stenosis

Ref Updated: 8/24/12

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