Bilateral Renal Artery Stenosis — ESENeph MCQ

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ModerateHypertensionBilateral Renal Artery StenosisESENeph

A 55-year-old woman presents with resistant hypertension (BP 160/95 on four antihypertensives). She has CKD G3a, bilateral small kidneys, and flash pulmonary oedema. MRA shows bilateral renal artery stenosis. What is the most likely underlying aetiology in a 55-year-old?

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Correct answer: E — Atherosclerotic renal artery stenosis

In patients over 50, bilateral renal artery stenosis is most commonly due to atherosclerotic disease. Risk factors include smoking, hypertension, diabetes, and dyslipidaemia. Flash pulmonary oedema (Pickering syndrome) is a characteristic presentation of bilateral RAS. Fibromuscular dysplasia typically affects younger women and involves the mid/distal renal artery. Management involves medical therapy (including ACEi/ARB with close monitoring), cardiovascular risk reduction, and consideration of angioplasty/stenting only for refractory symptoms or flash pulmonary oedema.

Reference: ESC 2018 – Peripheral Arterial Disease; NICE CKD Pathway