How should I monitor patients with renal artery stenosis after initiating treatment?

After initiating treatment for renal artery stenosis, monitoring should primarily follow the guidelines for chronic kidney disease (CKD), with the frequency tailored to the individual patient's condition ¹,²,³.

• Regular Follow-up: Arrange regular follow-up in primary care, with the frequency determined by clinical judgment ¹,².
• eGFR and Albumin:Creatinine Ratio (ACR) Monitoring:
  • Monitor eGFR and ACR regularly, with the minimum frequency guided by the patient's eGFR and ACR categories ¹,²,³. For example, a patient in GFR category G3a with ACR category A3 would typically require eGFR monitoring twice a year ³.
  • Tailor the monitoring frequency based on the underlying cause of CKD (e.g., renal artery stenosis), the rate of decline in eGFR or increase in ACR, other risk factors (such as heart failure, diabetes, and hypertension), and changes to their treatment (e.g., renin-angiotensin-aldosterone system [RAAS] antagonists) ¹,²,³.
  • Be aware that small fluctuations in eGFR and ACR do not necessarily indicate disease progression ¹,². To assess the rate of progression, repeat serum eGFR three times over a minimum of 3 months ¹,².
• Blood Pressure Management:
  • Assess for hypertension and aim to keep blood pressure below specific targets based on the ACR ¹,².
  • If ACR is less than 70 mg/mmol, aim for a clinic systolic blood pressure below 140 mmHg (target range 120–139 mmHg) and diastolic blood pressure below 90 mmHg ¹,².
  • If ACR is 70 mg/mmol or more, aim for a clinic systolic blood pressure below 130 mmHg (target range 120–129 mmHg) and diastolic blood pressure below 80 mmHg ¹,².
• Medication Review and Acute Kidney Injury (AKI) Risk:
  • Identify any potentially nephrotoxic drugs that may cause AKI during severe intercurrent illness, and reduce or stop them as appropriate ¹,².
  • Consider temporarily stopping ACE inhibitors and ARBs in patients with diarrhoea, vomiting, or sepsis until their clinical condition has improved and stabilised ⁵.
  • Monitor serum creatinine regularly in all adults with or at risk of AKI ⁵.
• Monitoring for Disease Progression and Complications:
  • Assess for and manage risk factors and comorbidities of CKD, including lifestyle factors and cardiovascular disease risk ¹,².
  • Define accelerated progression of CKD as a sustained decrease in GFR of 25% or more and a change in GFR category within 12 months, or a sustained decrease in GFR of 15 mL/min/1.73 m2 within 12 months ¹,²,³.
  • If progression is present, assess for any reversible causes (such as potentially nephrotoxic drugs or volume depletion) ¹,².
  • Consider a renal tract ultrasound scan if there is accelerated progression of CKD, visible or persistent invisible haematuria, symptoms of urinary tract obstruction, or a GFR of less than 30 ml/min/1.73 m2 (GFR category G4 or G5) ³.
  • Arrange a full blood count (FBC) to exclude renal anaemia for people with CKD category G3-G5 and in other people if clinically indicated ¹,².
• Referral to Specialist:
  • If hypertension remains uncontrolled despite the use of at least four antihypertensive drugs at therapeutic doses, arrange referral to a nephrology specialist ¹,².
  • If renal anaemia is suspected, arrange referral to a nephrology specialist for further assessment and management ¹,².
  • If CKD progression is present, arrange referral to a specialist kidney service for further assessment and management ¹,².