Atherosclerosis is the most common cause of renovascular disease and can result in hypertension and ischemic nephropathy. Natural history studies have shown that atherosclerotic renal artery stenosis tends to progress over time. Risk factors associated with disease progression include systolic hypertension, diabetes mellitus, and severe renal artery stenosis. Kidneys with stenotic renal arteries are also at risk for atrophy and deterioration in renal function. Early renal revascularization may improve this natural history; however, randomized clinical trials will be necessary to define the role of renal revascularization in this setting. Duplex ultrasound is a reliable screening test for renal artery stenosis that provides distinct advantages in terms of cost and risk compared with other imaging techniques. Ultrasound may also be valuable in predicting the functional response to renal artery interventions. Computed tomography (CT) and magnetic resonance angiography (MRA) are accurate anatomic tests for renal artery disease, but spiral CT requires relatively high volumes of iodinated contrast. MRA permits visualization of the main renal arteries and accessory renal arteries without ionizing radiation or iodinated contrast. Screening by either duplex ultrasound or MRA should limit the use of contrast arteriography to those patients who are candidates for direct renal artery interventions.
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