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Treatment

In the absence of timely adequate treatment, patients with renovascular hypertension develop severe cardiovascular complications and / or chronic renal failure. This determines the importance of timely diagnosis and, when confirming the diagnosis of "renovascular hypertension," referral to specialized centers to determine treatment tactics. Currently, there are three approaches to the treatment of patients with renovascular hypertension: drug therapy, surgical revascularization, and intravascular balloon angioplasty. These treatment methods do not exclude, but complement each other.

Drug therapy in patients with renovascular hypertension, as in all patients with high blood pressure, is primarily aimed at reducing its level. Target blood pressure in patients with renovascular hypertension should not differ from that in patients with other forms of hypertension: it is necessary to strive to achieve a level of <140/90 mm Hg. Art. for all patients without signs of impaired renal function, <130/80 - in the presence of symptoms of kidney damage, as well as <125/75 mm RT. Art. - with proteinuria> 1 g / day.

If there is evidence of an atherosclerotic process, in addition to antihypertensive therapy, appropriate therapy is carried out: smoking cessation is recommended, statins are prescribed to correct dyslipidemia and acetylsalicylic acid. With non-specific aortoarteritis, additional treatment should be aimed at suppressing the activity of the inflammatory process. The same treatment is continued after interventional or surgical treatment.

Medication antihypertensive therapy with the established diagnosis of "renovascular hypertension" is performed for all patients:

• before surgical or interventional intervention - in preparing patients with renovascular hypertension for surgical or interventional treatment;

• with residual hypertension - in cases of insufficient antihypertensive effect after carrying out revascularization procedures, as a rule, in most patients with atherosclerotic stenosis;

• for primary and secondary prevention of severe cardiovascular complications when surgical treatment cannot be performed;

• if the patient refuses to carry out endovascular interventions and / or surgical treatment.

Since renovascular hypertension is characterized by a course with a high level of blood pressure (2-3rd degree of increase in blood pressure), taking into account current recommendations, it is advisable to prescribe combination antihypertensive therapy with long-acting drugs from the very beginning. When choosing antihypertensive drug therapy, preference is given to drugs from the group of calcium channel blockers, the intake of which does not impair renal perfusion (recommendation class I, level of evidence A). Without additional restrictions, β-adrenoreceptor blockers (recommendation class I, level of evidence A), diuretics, and possibly α-adrenergic blockers and imidazoline receptor agonists can be used.

The main place in the treatment of patients with renovascular hypertension is occupied by drugs that block the activity of RAAS - ACE inhibitors, and, potentially, ARB II. It must be emphasized that uncontrolled therapy with ACE inhibitors and ARB II inhibitors can lead to impaired renal function, especially with its initial decrease. Reducing the formation of A II and the weakening of its vasoconstrictor effect on efferent arterioles while taking drugs that block RAAS, leads to a decrease in intracubule pressure and glomerular filtration, which can lead to the development of acute renal failure. Long-term therapy with drugs of these groups is contraindicated in patients with bilateral renal artery stenosis or artery stenosis of a single functioning kidney.

To date, sufficient evidence has been accumulated of the effectiveness of ACE inhibitors in patients with renovascular hypertension due to unilateral stenosis. The vast majority of studies have been conducted in patients with atherosclerotic lesions of the renal artery. At the same time, a mandatory condition for drug treatment is constant monitoring of the functional state of the kidneys: it is necessary to regularly monitor the level of creatinine in the blood serum, proteinuria, and the dynamics of GFR. Serum creatinine should not increase by more than 10-15% compared with the initial level. The use of ACE inhibitors is effective even in patients with hypertension refractory to treatment with other antihypertensive drugs. It was also found that in addition to the antihypertensive effect, ACE inhibitor therapy provided an effective nephroprotective effect (recommendation class I, level of evidence A). Therapy with drugs of this group begins with low doses, which are then titrated to the maximum tolerated. Only with the use of ACE inhibitors at maximum doses can an effective nephroprotective effect be expected. It is also important to monitor serum potassium levels during treatment. With a tendency to hyperkalemia, it is not recommended to combine ACE inhibitors with potassium-sparing diuretics, including spironolactone. The use of ARB II in the treatment of renovascular hypertension is currently based on less evidence, their effectiveness has yet to be confirmed in specially designed clinical trials (recommendation class I, level of evidence B). The most effective combinations for ACE inhibitors and ARB II are considered to be their use in combination with diuretics and / or calcium channel blockers.

During long-term antihypertensive therapy in patients with a confirmed diagnosis of "renovascular hypertension", it is important to understand that even with adequate control of blood pressure, the persistent presence of unrepaired stenosis steadily leads to a progressive decrease in kidney function and its wrinkling, and in the absence of proper control of blood pressure, especially in patients with a malignant course of hypertension, leads to the development of nephrosclerosis in the contralateral kidney and to subsequent cardiovascular and other complications. Expectant tactics in such cases are unjustified: a referral to specialized centers is shown to determine the optimal way to eliminate renal artery stenosis.

A direct indication of both intravascular and surgical correction of renovascular hypertension is diagnosed, hemodynamically and functionally significant renal artery stenosis (> 50%).

For the correction of stenosis, various reconstructive interventions and operations are performed, the form of which is determined by the etiology and prevalence of damage to the renal arteries, abdominal aorta and its other branches. In determining the indications for intravascular and surgical treatment, a number of clinical factors are taken into account: the presence of concomitant pathology, primarily the degree of damage to the cardiovascular system, damage to the coronary vessels, the functional state of both kidneys, and the duration of the presence of hypertension. Contraindications for reconstructive vascular interventions are the terminal stage of renal failure and the presence of cerebral or coronary circulation disorders over the past 3 months. Intravascular or surgical intervention in patients with nonspecific aortoarteritis should be carried out in the phase of laboratory and morphological remission no earlier than 3 months after the normalization of laboratory parameters.

Persistent antihypertensive effect after intervention, depending on the etiology of the disease, is achieved in 30-80% of patients.
At the same time, full normalization of blood pressure is noted only in 25-50% of patients. In addition to the antihypertensive effect itself, revascularization allows stabilization of renal function and a decrease in the number and / or dose reduction of antihypertensive drugs necessary to achieve effective control of blood pressure. In the long term after intravascular or surgical intervention in 10-25% of patients, a relapse of renovascular arterial hypertension due to the progressive course of the underlying disease and the development of renal artery restenosis in the area of ​​angioplasty or the development of “fresh” stenosis or occlusion of another part of the renal artery requiring repeated endovascular or surgical intervention.?

In order to eliminate stenosis and normalize blood supply to the kidneys in the last 15 years, endovascular balloon dilatation is the most widely used - the expansion of the stenotic section of the renal artery using dilated balloon catheters. Currently, angioplasty is often used in combination with stenting of the affected artery (recommendation class 11A, level of evidence B). The advantages of this method are low morbidity, a shorter duration of the patient’s stay in the hospital, the possibility of using it in a heavy contingent of patients, in particular in elderly people with increasing renal failure (recommendation class 11A, level of evidence B), respiratory failure, in patients with unstable angina ( class of recommendations 11A, level of evidence B), CHF (class of recommendations I, level of evidence B), with a crisis course of AH. The introduction of stenting compared with conventional angioplasty has increased the effectiveness of the revascularization procedure, to provide better long-term results of patency of the artery and to reduce the frequency of restenosis. The effectiveness of this treatment method does not depend on the age and gender of the patients.

The use of angioplasty and stenting of the renal arteries leads to normalization of blood pressure or an improvement in the course of arterial hypertension in the vast majority (over 90%) of patients with fibromuscular dysplasia during the follow-up period of up to 3 years. However, only 50% of these patients can completely refuse to take antihypertensive drugs (Mansoor G., 2004). In addition, over the same period, in 8–25% of cases, restenosis develops in the area of ​​previously performed angioplasty with relapse of renovascular hypertension, which requires repeated x-ray surgical interventions.

In patients with atherosclerotic lesions of the renal vessels, the effectiveness of intravascular interventions is much lower: improvement in the condition of patients is noted in 50-60% of cases, the ability to completely stop taking antihypertensive drugs in less than 10% of patients (Morganti A., 2000). A meta-analysis of the effectiveness of renal artery stenting for atherosclerotic lesions demonstrated a high efficacy of the procedure itself (98%) and an acceptable incidence of restenosis (17%) (Leertouwer T. et al., 2000). A direct comparison of the effectiveness of interventional approaches and isolated drug treatment confirmed the advantages of the revascularization strategy in improving blood pressure control and preventing the development of renal failure.

The effectiveness of surgical revascularization in renal artery stenosis is quite high - normalization of renal perfusion is achieved in 97% of cases. Nevertheless, in recent years there has been a significant narrowing of the indications for surgical revascularization. This is due to the development of intravascular interventional technologies, improving the results of drug treatment. A direct comparison of the results of traditional surgical and intravascular balloon revascularization in patients with renovascular hypertension with atherosclerotic lesion, conducted by H. Weibull et al (1993), did not reveal the advantages of the surgical method over intravascular intervention during 2 years of observation. Thus, the authors recommended balloon angioplasty for patients who have a choice between intravascular intervention and the traditional surgical method of treatment.

The ACC and AHA2005 Recommendations (ACC / AHA 2005 Practice Guidelines for the Management of Patients With Peripheral Arterial Disease) clearly define current indications for surgical treatment of renal artery stenotic lesions: full-blown surgery is indicated for patients with fibromuscular dysplasia in the presence of complex vascular lesions involving segmental arteries and the presence of macroaneurysms (recommendation class I, level of evidence B), in patients with multiple atherosclerotic lesions of small-caliber arteries or primary tdelov main renal artery (recommendation class I, Grade V) in patients with atherosclerotic lesion with the need for reconstructive surgery on the aorta (class recommendations I, Grade C). The type of surgery (endarterectomy, bypass surgery, or more complex reconstructive angioplastic interventions) is determined by the type and volume of vascular lesions, the state of the aorta, and the severity of the patient's condition.

An important point is the decision to conduct a nephrectomy. Nephrectomy is performed only in cases when reconstructive surgery is no longer feasible: with an irreversible lesion or ischemic kidney atrophy. Its clinical signs are: a decrease in kidney size <5 cm, an affected kidney provides <10% of total renal function, the presence of signs of common cortical heart attack of the kidney.

After any endovascular or surgical interventions on the renal arteries, patients with renovascular hypertension should be followed up with regular monitoring of blood pressure and patency of the artery reconstruction zone (by ultrasound, magnetic resonance angiography and other non-invasive diagnostic methods). According to them, in the course of dynamic monitoring, a comprehensive antihypertensive and lipid-lowering therapy is carried out, as well as correction of concomitant risk factors for cardiovascular complications. In addition to providing an antihypertensive effect, complex drug therapy of renovascular hypertension requires the need to influence the main pathogenetic process in establishing the etiology of hypertension. Therapy of renovascular hypertension of atherosclerotic etiology includes the use of low-dose lipid-lowering drugs (statins) and acetylsalicylic acid. There is evidence that prolonged use of statins for atherosclerotic lesions of the vessels of the kidneys provides a nephroprotective effect in this category of patients. Anti-inflammatory therapy for renovascular hypertension against the background of nonspecific aortoarteritis should be aimed at suppressing the activity of the inflammatory process and its prevention. GCS and cytostatics are used for this purpose. If a stratified aneurysm of the abdominal aorta is detected, the patient should be urgently referred to specialized vascular surgery centers for the necessary treatment.
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