This elderly patient who has uncontrolled hypertension despite multidrug therapy and is found to have high-grade bilateral renal artery stenosis (>60% stenosis) should be treated with an ACE inhibitor.
Bilateral renal ischemia (caused by limited blood supply to the poststenotic kidney) induces the activation of the renin-angiotensin-aldosterone system (RAAS), which leads to sodium retention and volume expansion. As the RAAS is involved, a combination of a diuretic with an ACE inhibitor or angiotensin receptor blocker (ARB) is the preferred initial treatment. ACE inhibitors have been shown to decrease mortality, rate of myocardial infarction, progression to end-stage renal disease, and stroke and are equally as effective as angioplasty in most patients.
Patients with bilateral renal artery stenosis are at increased risk of development of acute kidney injury; however, ACE inhibitors and ARBs are ==no longer thought to be contraindicated== in this population as most patients only experience a small decline in glomerular filtration rate. More marked declines are usually reversible with dose reduction or elimination of the diuretic; patients should be monitored closely while on these medications. Other antihypertensive agents and statins, as well as antiplatelet therapy should be added when appropriate along with lifestyle changes.
Patients who fail optimal medical therapy (eg, refractory hypertension, inability to tolerate medications, progressive renal insufficiency) or those with recurrent flash pulmonary edema or heart failure should undergo revascularization with stenting (Choice D).