• Treatments for Renal Artery Disease

     
     
     
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    12/01/2009
    The earlier renal artery disease is diagnosed and the sooner treatment begins, the better your prospects for slowing its progress and avoiding high blood pressure and kidney failure. 

    A number of treatment options are available. Your physician will consider the full spectrum of options in deciding what is best for you.

    Most physicians will recommend lifestyle changes and medications as the first line of treatment for mild renal artery disease. If renal artery disease becomes worse, more aggressive procedures, including angioplasty (a procedure to widen blood vessels) and surgery, may be recommended.

    Lifestyle Changes 

    Your doctor will recommend that you modify your lifestyle – stop smoking if you haven’t already, begin eating a healthy diet and exercising regularly and achieve your ideal body weight. Lifestyle modifications will help prevent or slow the progress of diseases of the blood vessels.

    Medical Therapy

    Your doctor may prescribe medications that reduce risk factors for renal artery disease and can help slow its progression. Medications that may be prescribed include those that help:

    1. Control Your Blood Pressure

    High blood pressure (also called hypertension) can be caused by blockages in the arteries to the kidneys. And it can also be a risk factor for developing renal artery disease. – as well as heart attack, stroke, kidney disease and eye problems. By taking steps to lower and control your blood pressure, you can help delay or prevent renal artery disease. and a range of other health problems.

    Your doctor may prescribe one or more medications to help control your blood pressure. See the  table below to learn more about these medications.

    2. Control Your Cholesterol

    If you have renal artery disease, you can reduce your risk of heart attack or stroke by controlling your cholesterol level. 

    Depending on your symptoms, your doctor may prescribe one or more types of cholesterol-lowering medications, each of which acts in a different way to address cholesterol levels in your blood The main types of cholesterol-control medications include:

    • Statins (Lipitor, Zocor and Pravachol) to prevent inflammation – and clot formation – in arteries where plaque has built up.
    • Fibric acid derivatives, such as Lopid and Tricor, drugs that lower triglyceride levels (triglycerides are another type of fat in the arteries).
    • Niacin (also called nicotinic acid) to raise your HDL “good cholesterol” level.
    • Other medications may include cholesterol absorption inhibitors, such as ezetimube (Zetia) which works to reduce the amount of cholesterol the body absorbs, and bile acid sequestrants, such as cholestyramine (Questran), colestipol (Colestid) and colesevelam (Welchol). These medications help rid the body of bile acids. This causes the liver to replace the lost bile acids by converting more cholesterol into bile acids – a process that reduces the level of cholesterol in the blood.

    Be sure to ask your doctor what the medicines are for and how and when you should take them. And don’t hesitate to let your doctor know if you have side effects. There may be other medications that work better for you.

    3. Manage Your Diabetes

    The increasing rate of obesity is contributing to a higher rate of diabetes. And with the increase in diabetes, it is becoming the most common – and a serious – risk factor for renal artery disease. If you have diabetes, your risk of also developing renal artery disease is higher than for people who do not have diabetes. And if you have renal artery disease. and diabetes, your risk for progressive renal artery disease, high blood pressure and kidney failure, as well as heart attack or stroke is much higher than for people who have renal artery disease only. Your risk of dying at a younger age may also be higher. 

    So, if you have diabetes, it’s vitally important that you not only manage your diabetes but also take care of your blood vessels. Medical guidelines for the treatment of diseases of the blood vessels recommend that people over age 50 with diabetes be tested for renal artery disease. They also recommend testing for people under age 50 with diabetes who also have risk factors for renal artery disease, including smokinghigh blood pressure and high cholesterol. 

    You may also need to take medications to achieve your blood glucose, blood pressure and cholesterol targets. You may also want to ask your doctor about taking antiplatelet medications, such as aspirin or clopidogrel (Plavix®), that thin the blood to help prevent  blood clots, which can lead to heart attack or stroke. 

    Over time, it may be necessary to change your medications to achieve your target goals. For example, if you need insulin shots for diabetes, it may not mean that the diabetes if getting worse, but that you need a new approach to achieving your target numbers. 

    4. Prevent Blood Clots

    If you have renal artery disease, you may be at high risk for a heart attack or stroke caused by a blood clot. However, certain medications have been shown in studies to help prevent blood clots from forming.

    When a clot forms inside the blood vessels, though, it can limit or block blood flow. And if the clot itself breaks loose, it can lodge in a blood vessel supplying the heart or brain, blocking blood flow. In either case, a heart attack or stroke may occur. 

    Fortunately, there are steps you can take to prevent blood clots or reduce the likelihood that they will form. Adopting a healthy lifestyle, including eating a healthy diet, getting regular exercise and avoiding  smoking, is essential. Taking antiplatelet medications may also help stop blood clots from forming and lower the risk of heart attack or stroke. Antiplatelet drugs act to thin the blood, making it less likely that blood cells will clump together to form clots. 

    Taking Anti-Platelet Medications
    The two most frequently prescribed anti-platelet medications are aspirin and clopidogrel, or Plavix®.

    • The typical dosage of aspirin may range from 75 to 325 mg daily. (Low-dosage aspirin may be referred to as “baby aspirin.”) Coated aspirin, which passes through the stomach without dissolving, may be recommended to reduce side effects, such as stomach irritation, pain, nausea, vomiting or bleeding. Be sure to tell your doctor know if you are allergic to aspirin, tend to bleed or have had bleeding in your digestive tract or have liver disease.
    • A prescription of 75 mg of clopidogrel is typical. You should avoid taking clopidogrel if you have a stomach ulcer or another condition that causes bleeding. Or, if you are having a procedure – angioplasty, stenting or surgery – to treat blocked blood vessels, make sure your doctor knows you’re taking the drug.
    • Often, both aspirin and clopidogrel are recommended. Your health care provider will work with you to determine the medications that are best for you.

    Endovascular and Surgical Procedures

    If you need more aggressive treatment than medications and lifestyle changes, your physician may recommend an endovascular or surgical procedures to treat blockages in your arteries. Both treatments aim to restore blood flow to the kidneys. When blood flow is restored, kidney function improves and high blood pressure resulting from a blocked renal artery may be lowered. After treatment of a renal artery, you may still have high blood pressure, but you may need less medication to control it. 

    Endovascular Procedures

    An endovascular procedure is one that is performed inside the blood vessels through the use of a small, flexible tube, called a catheter. It is performed by a doctor with special endovascular training. Among the medical specialists who may treat renal artery disease are interventional cardiologists, vascular surgeons, interventional radiologists and vascular medicine specialists. 

    There are a number of endovascular procedures that may be recommended for the treatment of renal artery disease, but the two most common are balloon angioplasty and stenting. These procedures have been used for decades to treat blocked arteries to the heart in order to restore blood flow and prevent or stop chest pain, heart attack and stroke. 

    Balloon angioplasty
    During a balloon angioplasty procedure, a specially trained physician places a thin, flexible tube, or catheter, into an artery – usually gaining access to the vessel via a tiny puncture made in the groin. The doctor then uses x-ray images to guide the catheter, which has a tiny uninflated balloon on the tip, through the arteries to the point of the blockage. As the balloon is inflated, deflated and reinflated (often several times), it flattens the fatty deposits against the inside of the artery wall to widen the channel. Once the artery is widened, the balloon is deflated and removed.

    Stenting
    Once an artery is opened, a stent may be placed at the location in the artery where the angioplasty was performed to help prop the vessel open. A stent is a small metal, mesh tube that is delivered to the site via the catheter. Once placed in the artery, the stent is expanded so that it serves as scaffolding to prevent the artery from collapsing. The stent eventually becomes embedded in the artery wall.

    Recovery 
    Immediately after angioplasty and stenting, you may be asked to lie still for several hours to prevent bleeding from the wound where the catheter was inserted. Many people return home the day of the procedure or stay in the hospital overnight. Most are able to resume normal activities within just a few days. 
    To keep your vessels from clogging again and to protect your health, it is extremely important to take the medications prescribed by your doctor and to exercise regularly, eat a healthy diet, manage your diabetes and avoid smoking. 

    If the blockage returns
    Arteries can become blocked again after they have been treated. A re-narrowing of the artery, called restenosis (REE-sten-o-sis), may cause you to again experience high blood pressure or other complications due to renal artery disease. A second procedure may be needed to widen the artery again.

    Surgery

    Surgeons use one of two surgical procedures to treat renal artery disease:

    • Endarterectomy, in which the surgeon removes the inner lining of the renal artery (as well as the plaque that causing the blockage)
    • Bypass surgery, in which the surgeon creates a detour or bypass around the portion of the artery that is blocked or narrowed to provide a channel for blood to continue to flow to the kidneys. A vein taken from another part of your body, or a tube made of man-made materials, is attached above and below the blockage to create the detour.

    Recovery
    Immediately after surgery, you will be closely monitored to ensure that blood is flowing to your kidneys and that your vital signs are good. You will be given medicine to control pain. After a few days when you are able to walk on your own, you will be released from the hospital. 
    After you leave the hospital, it is very important to take all the medications your doctor has prescribed and follow all instructions for caring for your incision. It is also vital that you make all your follow up visits to the doctor to ensure that the blood is flowing properly to your kidneys, 
    What if the blockage returns?

    After surgery, the renal arteries usually remain open. If your arteries become narrow again after they have been treated, a condition called restenosis (REE-sten-o-sis), you may need a second procedure.

    Table 1. Blood Pressure Medications

     

    Generic name (Brand name)

    Action to lower blood pressure

    Diuretics

    · Amiloride (Midamor)
    · Bumetanide (Bumex)
    · Chlorothiazide (Diuril)
    · Chlorthalidone (Hygroton)
    · Furosemide (Lasix)
    · Hydrochlorothiazide (Esidrix, Hydrodiuril)
    · Indapamide (Lozol)
    · Spironolactone (Aldactone)

    Cause the body to rid itself of excess fluids and sodium through urination.

    ACE Inhibitors 
    (Angiotensin-Converting Enzyme Inhibitors)

    · Benazepril (Lotensin)
    · Captopril (Capoten)
    · Enalapril (Vasotec)
    · Fosinopril (Monopril)
    · Lisinopril (Prinivil, Zestril)
    · Moexipril (Univasc)
    · Perindopril (Aceon)
    · Quinapril (Accupril)
    · Ramipril (Altace)
    · Trandolapril (Mavik)

    Block a key enzyme responsible for high blood pressure, thereby reducing the heart’s workload.

     

    Angiotensin-2 Receptor Antagonists

    · Candesartan (Atacand)
    · Eprosartan (Teveten)
    · Irbesartan (Avapro)
    · Losartan (Cozaar)
    · Telmisartan (Micardis)
    · Valsartan (Diovan)

    Produce effects similar to those of ACE Inhibitors. May be better tolerated: Produces less cough and other reactions.

     

    Beta Blockers

    · Acebutolol (Sectral)
    · Atenolol (Tenormin)
    · Betaxolol (Kerlone)
    · Bisoprolol/hydrochlorothiazide (Ziac)
    · Bisoprolol (Zebeta)
    · Carteolol (Cartrol)
    · Metoprolol (Lopressor, Toprol XL)
    · Nadolol (Corgard)
    · Propranolol (Inderal)
    · Sotalol (Betapace)
    · Timolol (Blocadren)

    Decrease the heart rate and force of blood pumped from the heart to lower blood pressure. Also used with therapy for cardiac arrhythmias and in treating chest pain.

    Calcium Channel Blockers 
    (Also called Calcium Antagonists or Calcium Blockers)

    · Nisoldipine (Sular)
    · Nifedipine (Adalat, Procardia)
    · Nicardipine (Cardene), 
    · Bepridil (Vascor)
    · Isradipine (Dynacirc) Nimodipine (Nimotop)
    · Felodipine (Plendil)
    · Amlodipine (Norvasc)
    · Diltiazem (Cardizem) 
    · Verapamil (Calan, Isoptin)

    Block calcium from entering the muscle cells of the heart and arteries. (Calcium in the cells causes the heart to contract and arteries to narrow.) By blocking calcium, contraction of the heart is decreased and arteries are widened.

    Central Alpha Agonists

    · Clonidine hydrochloride (Catapres)
    · Clonidine hydrochloride and chlorthalidone (Clorpres, Combipres)
    · Guanabenz Acetate (Wytensin)
    · Guanfacine hydrochloride (Tenex)
    · Methyldopa (Aldomet)
    · Methyldopa and chlorothiazide (Aldochlor)
    · Methyldopa and hydrochlorothiazide (Aldoril)
    ·

    Lower blood pressure by blocking nerve impulses that cause small arteries to constrict or become narrow, thus easing blood flow. Usually prescribed when all other blood pressure medications have failed.

    Peripherally Acting Alpha Agonist

    · Prazosin (Minipress,Vasoflex, Hypovase)
    · Indoramin (Baratol)
    · Doxazosin (Cardura and Carduran)

    Lower blood pressure by relaxing the blood vessels.