This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kuroda, S. Articles by Kimura, G. Search for Related Content PubMed PubMed Citation Articles by Kuroda, S. Articles by Kimura, G. Pubmed/NCBI databases Medline Plus Health Information Stroke

(Stroke. 2000;31:61.)
© 2000 American Heart Association, Inc.

Original Contributions

Prevalence of Renal Artery Stenosis in Autopsy Patients With Stroke

Setsuko Kuroda, MD; Naoki Nishida, MD; Takashi Uzu, MD; Masanobu Takeji, MD; Masataka Nishimura, MD; Takashi Fujii, MD; Satoko Nakamura, MD; Takashi Inenaga, MD; Chikao Yutani, MD Genjiro Kimura, MD

From the Divisions of Nephrology (S.K., T.U., M.T., M.N., T.F., S.N., T.I., G.K.) and Pathology (N.N., C.Y.), National Cardiovascular Center, Osaka, Japan.

	Abstract

Top Abstract Introduction Methods Results Discussion References

 
Background and Purpose—Atherosclerotic renal artery stenosis commonly exists as one manifestation of more generalized atherosclerosis. It is a progressive but potentially curable disorder. Thus, information on renal artery involvement in atherosclerotic diseases could be important. We investigated the prevalence of renal artery stenosis in autopsied patients with stroke over 40 years of age.

Methods—From 2167 consecutive autopsy patients who died between 1980 and 1997, we studied 346 cases of mean age of 69±11 years with clinical evidence of stroke.

Results—Atherosclerotic renal artery stenosis (75% luminal area narrowing) was found in 36 patients (10.4%). Patients with renal artery stenosis were older and had worse renal function. Renal artery stenosis was found in 14.7%, 28.6%, and 23.9% of patients with hypertension, renal insufficiency, and aortic aneurysm, respectively. Extracranial carotid artery stenosis (>50% luminal area narrowing) was found in 101 patients (29.2%). Of the 346 stroke patients, 256 had a history of brain infarction. In patients with brain infarction, renal artery stenosis was found in 31 (12.1%) and carotid stenosis was found in 81 (33.6%). Patients with carotid artery stenosis were more likely to have renal artery stenosis than patients without carotid artery stenosis (24.4% versus 5.9%, P<0.0001). Multiple logistic regression analysis identified renal insufficiency, hypertension, female gender, and presence of carotid artery stenosis as independent predictors of renal artery stenosis in patients with brain infarction.

Conclusions—These data reveal that atherosclerotic renal artery stenosis is common in patients with stroke, especially in those with brain infarction.

Key Words: autopsy • hypertension • carotid stenosis • renal artery • stroke

	Introduction

Top Abstract Introduction Methods Results Discussion References

 
Atherosclerotic renal artery stenosis is an important cause of hypertension and renal insufficiency. Early autopsy studies confirm that mainly elderly patients are affected.^{1 2} Several angiographic studies have shown that renal atherosclerosis usually exists as one manifestation of more generalized atherosclerosis,² including symptomatic peripheral vascular disease, aortic aneurysm,³ and ischemic heart disease.⁴ Renal artery stenosis is progressive^{5 6} and potentially leads to end-stage renal disease.² It may account for between 10% and 20% of patients on dialysis in some surveys.^{7 8} The increased mortality was observed in patients with renal artery stenosis, because they have comorbid cardiovascular disease and greater age.^{6 7 9} Revascularization procedures of the renal artery are frequently clinically useful.^{2 10 11 12 13} Thus, information on renal artery involvement in atherosclerotic disease could be important in the overall treatment of the patients, as well as in the clinical outcome.

We have recently reported, on the basis of autopsy study, that renal artery stenosis is common in patients with myocardial infarction.¹⁴ Stroke is another important atherosclerotic disease, but the prevalence of renal artery stenosis has not been reported. The prevalence is probably high, because stroke event rate has been closely related to carotid atherosclerosis,^{15 16} and extracranial vascular atherosclerosis is increasing in Japanese patients with brain ischemia.¹⁷ The aim of this study is to determine the prevalence of atherosclerotic renal artery stenosis in stroke patients on the basis of autopsy study. In addition, we tried to analyze the predictive factors of high-risk patients with atherosclerotic renal artery stenosis.

	Methods

Top Abstract Introduction Methods Results Discussion References

 
Patients
During the 17-year period between 1980 and 1997, 2167 patients were autopsied at National Cardiovascular Center Hospital in Osaka, Japan. To examine atherosclerotic renal artery stenosis in elderly patients, we studied retrospectively all the autopsy cases for patients aged 40 years who had a history of stroke. Patients with nephrectomy (n=8), horseshoe kidney (n=2), renal cell carcinoma (n=5), or dissecting aneurysm of the aorta involving the renal artery (n=2) or carotid artery (n=4) were excluded from this study. We also excluded patients without precise information on the renal artery (n=12) and carotid artery (n=13). Two patients who had received endarterectomy of carotid artery because of severe atherosclerotic stenosis were included. A total of 346 patients remained for analysis.

Hypertension was diagnosed when blood pressure was 140 and/or 90 mm Hg on at least 2 different visits to the hospital, or if the patient was taking antihypertensive agents. Diabetes mellitus was defined as a patient’s use of oral hypoglycemic agents or insulin, and/or having a fasting blood glucose level 7.8 mmol/L (140 mg/dL) or random nonfasting blood glucose level 11.1 mmol/L (200 mg/dL). Hypercholesterolemia was defined as a patient’s taking lipid-lowering agents and/or having a serum cholesterol level 5.7 mmol/L (220 mg/dL). Proteinuria was diagnosed as urinary protein level >1(+) by the dye-impregnated paper strip method and renal insufficiency as a serum creatinine level >133 µmol/L (1.5 mg/dL). Laboratory data, including serum creatinine, cholesterol, glucose, and urinalysis, were collected within 1 year before the fatal event that led to death (ie, septemia and multiple organ failure). The types of stroke were classified from the clinical history, neurological examination, and findings of CT and/or MRI scans, according to the National Institute of Neurological Disorders and Stroke Classification of Cerebrovascular Disease III. We did not categorize the infarct into subtypes such as atherothrombotic, cardioembolic, and lacunar infarction. The cases with asymptomatic cerebrovascular disease and transient ischemic attack were not included in this study.

Autopsy Study
According to the regulations of our pathology department, the thoracoabdominal aorta, brachiocephalic artery, extracranial carotid arteries, renal arteries, and kidneys were removed on block. Bilateral extracranial carotid arteries (including common carotid and internal carotid arteries) and renal arteries were dissected. Macroscopically apparent stenosis of 75% luminal area narrowing was defined as renal artery stenosis. Carotid artery stenosis was defined as >50% luminal area narrowing. All carotid arteries and renal arteries were reviewed by 2 pathologists (N.N. and C.Y.) under blinded conditions for clinical information. The specimen of these arteries were reviewed by them together, and the final decision was made through a consensus meeting after discussion. Known or suspected aortic aneurysm and coronary artery disease were confirmed by autopsy study.

Statistical Analysis
Significance of the differences between the 2 groups was analyzed by the Student t test, ² analysis, or Fisher exact test on an appropriate basis. Multiple logistic regression analysis was performed with use of a maximum likelihood function to identify predictors and risk factors of significant renal artery stenosis. Independent valuables were age, sex, presence of hypertension, diabetes mellitus, hypercholesterolemia, proteinuria, renal insufficiency, smoking history, coronary artery disease, aortic aneurysm, and carotid artery stenosis. Data were expressed as the mean±SD.

	Results

Top Abstract Introduction Methods Results Discussion References

 
Among 2167 autopsy cases between 1980 and 1997, the autopsy protocols of 392 patients with a clinical history of stroke and age 40 years were referred for possible enrollment; 346 were finally included. Types of stroke were the following: brain infarction (n=219), subarachnoid hemorrhage (n=36), brain hemorrhage (n=51), brain infarction plus subarachnoid hemorrhage (n=8), brain infarction plus hemorrhage (n=29), and subarachnoid plus brain hemorrhages (n=3).

The clinical characteristics of the studied cases are summarized in Table 1. The mean age of the patients was 69±11 years. Hypertension was recognized in 63.4% of patients and proteinuria in 35.5%. Renal insufficiency was noted in 22.4%. The mean serum creatinine concentration was 302±240 µmol/L (3.4±2.7 mg/dL) in patients with renal insufficiency, while it was 89±24 µmol/L (1.0±0.3 mg/dL) in those without it.

View this table: [in this window] [in a new window]   Table 1. Clinical Characteristics of Autopsy Patients With Stroke

Of the 346 patients, 36 patients (10.4%) had atherosclerotic renal artery stenosis. Twenty-six (7.5%) had unilateral disease (16 stenosis and 10 occlusion), while 10 (2.9%) had bilateral disease (2 bilateral occlusion, 4 with occlusion and stenosis, and 4 bilateral stenosis). Renal artery occlusion was, therefore, present in 4.6% of patients. Only 8 of the 36 cases (22.2%) had the established diagnosis of renal artery stenosis before autopsy.

Location and volume of the clinically relevant brain infarction or hemorrhage, illustrated by CT and/or MRI, was not different between patients with and without renal artery stenosis. Patients with renal artery stenosis were older than those without (mean age 73 versus 69 years, respectively; P=0.02) and had worse renal function (mean creatinine 221 versus 124 µmol/L, respectively; P<0.001). Prevalence of the atherosclerotic renal artery stenosis increased with age: 0% and 2% in the age groups 40 to 49 and 50 to 59 years, respectively, and 11%, 13%, and 14% in the age groups 60 to 69, 70 to 79, and 80 years, respectively (Figure).

View larger version (56K): [in this window] [in a new window]   Figure 1. The prevalence of renal artery stenosis and age in autopsy patients with stroke. The number of patients with renal artery stenosis and the total number of patients are the numerator and denominator, respectively, within each column.

As shown in Table 2, of 346 stroke patients, 68 (19.7%) had 75% stenosis in at least 1 of the extracranial carotid arteries (45 unilateral and 23 bilateral), and 23 (6.6%) were carotid artery occlusion (4 bilateral and 19 unilateral). Stenosis of >50% was detected in 101 patients (29.2%; 68 unilateral and 33 bilateral). Of 101 patients, 23 (22.8%) with carotid artery stenosis had renal artery stenosis, the prevalence of which was significantly higher than in stroke patients without carotid stenosis (13 of 245, 5.3%; P<0.0001).

View this table: [in this window] [in a new window]   Table 2. Prevalence of Renal Artery Stenosis and Extracranial Carotid Artery Stenosis in Autopsy Patients With Stroke

Of 346 stroke patients, 256 had history of brain infarction (219 with brain infarction, 29 with brain infarction plus hemorrhage, 8 with brain infarction plus subarachnoid hemorrhage). The mean age was 71±10 years, including 164 men (64%) and 92 women (36%). Carotid artery stenosis was more common in men than in women (34.8% versus 19.8%, P<0.01 in all strokes, and 40.2% versus 21.7%, P<0.01 in brain infarction). In patients with brain infarction, the prevalence of renal artery stenosis was higher than in those without brain infarction (12.1 versus 5.6%, P=0.08). The prevalence of extracranial carotid artery stenosis was also higher in patients with brain infarction than without brain infarction (>50% carotid artery stenosis: 33.6% versus 16.7%, P=0.08; 75% stenosis: 24.6% versus 5.6%, P<0.0001).

Considering that carotid atherosclerosis is frequently associated with ischemic stroke events, we examined the relationship between renal artery and extracranial carotid artery stenosis in patients with brain infarction. Renal artery stenosis was observed in 21 patients (24.4%) with carotid artery stenosis (>50%) and in 10 patients (5.9%) without carotid artery stenosis (P<0.0001). Conversely, 67.7% of patients with renal artery stenosis had carotid artery stenosis.

Table 3 shows the predictors and risk factors of renal artery stenosis in cases with all strokes and brain infarction. The prevalence of renal artery stenosis in all strokes was significantly higher in patients with hypertension, renal insufficiency and aortic aneurysm than in those without the respective factors. Renal artery stenosis was found in 14.7%, 28.6%, and 23.9% of stroke patients with hypertension, renal insufficiency, and aortic aneurysm, respectively. When we selected patients with brain infarction, renal artery stenosis was found in 17.3%, 34.6%, and 27.5% with the above factors, respectively. Proteinuria also affected the prevalence of renal artery stenosis in patients with brain infarction (17.8%). Patients with renal artery stenosis were more likely to have hypertension (90%), renal insufficiency (58%), aortic aneurysm (35%), and proteinuria (53%) in brain infarction. Diabetes, hypercholesterolemia, smoking, and coronary artery disease did not affect the prevalence of renal artery stenosis in patients with stroke or brain infarction. Gender difference was not observed.

View this table: [in this window] [in a new window]   Table 3. Association of Clinical Characteristics With Renal Artery Stenosis in Autopsied Cases With Stroke or Brain Infarction

Multiple logistic regression analysis identified the following variables for predicting renal artery stenosis: renal insufficiency, presence of carotid artery stenosis (>50%), hypertension, and female gender in patients with brain infarction (Table 4). Similar results were obtained in all of the stroke patients (data not shown). Taking carotid artery stenosis of 75% as an independent valuable, renal insufficiency and hypertension were accepted, but carotid artery stenosis and female gender became insignificant (Table 4). Age, presence of diabetes mellitus, hypercholesterolemia, proteinuria, smoking, coronary artery disease, and aortic aneurysm were not independent predictors of atherosclerotic renal artery stenosis in this population.

View this table: [in this window] [in a new window]   Table 4. Logistic Regression Analysis to Predict the Prevalence of Renal Artery Stenosis in Autopsy Patients With Brain Infarction

	Discussion

Top Abstract Introduction Methods Results Discussion References

 
This study identified predictors and risk factors for atherosclerotic renal artery stenosis in autopsied patients aged 40 years who had clinical history of stroke. In patients with renal insufficiency, hypertension, aortic aneurysm, or extracranial carotid artery stenosis, the prevalence of renal artery stenosis was higher than in those without the respective factors. Increasing age was also an important risk factor for renal artery atherosclerosis. Multiple logistic regression analysis showed that presence of renal insufficiency, carotid artery stenosis, and hypertension increased the prevalence of renal artery stenosis by 6.6-, 4.8-, and 4.1-fold in patients with brain infarction, respectively.

Of 346 stroke patients, 36 patients (10.4%) had significant renal artery stenosis; of these, 4.6% had renal artery occlusion and 2.9% had bilateral disease. In patients with brain infarction, the prevalence rate became 12.1%. We defined significant renal artery stenosis as 75% luminal area narrowing. The degree of renal artery stenosis, as we defined in this study, was almost the same as that of previous angiographic studies that defined significant renal artery stenosis as 50% or greater diameter narrowing.^{4 18}

There have been no population-based studies providing accurate data regarding the prevalence of renal artery stenosis. Several studies^{7 8 19} have suggested that renal artery stenosis may be responsible for 1% to 5% in unselected patients with hypertension, and 5% to 22% in patients aged 50 years with end-stage renal disease. In early autopsy studies,^{1 2} prevalence of renal artery atherosclerosis was reported to be increased in aged patients. Several angiographic studies reported that the prevalence of renal artery atherosclerosis ranges from 11% to 42% in patients with generalized arterial disease^{2 3 4} and 34% in elderly patients with congestive cardiac failure.²⁰ Our data were at the very low end of that range, at least in part because not all of the strokes were directly associated with atherosclerosis. In this study, cases with subarachnoid hemorrhage and cerebral hemorrhage were included as stroke patients, and cardioembolic infarction and lacunar infarction, both of which would occur in patients without atherosclerotic disease, were included as brain infarction. Hans et al²¹ reported that the prevalence of renal artery stenosis was 7.2% in patients who received carotid arteriography, including 14% of stroke, 44% of carotid stenosis, and 42% of transient ischemic attack patients. This rate was lower than ours. One possible explanation for the difference is that patients with renal insufficiency may be excluded from their angiographic study to avoid acute renal failure due to radiocontrast-induced nephropathy.

Clinical suspicion of atheromatous renal artery stenosis was usually based on the higher age of patients who show an abrupt onset of hypertension, pulmonary edema with accelerated hypertension, progressive renal failure, presence of other atherosclerotic disease, and acute impairment in renal function during treatment with an angiotensin converting enzyme (ACE) inhibitor. Some reports demonstrated that hypercholesterolemia, smoking history,²² diabetes mellitus, and male gender also predicted renal artery stenosis in hypertensive patients among the atherosclerotic population. However, in this study, hypercholesterolemia, diabetes mellitus, and smoking history were not independent predictors, probably because these risk factors contributed to stroke independently of renal artery stenosis, being consistent with other reports in atherosclerotic population.^{4 7 14 18} In addition, female gender was an independent predictor of renal artery stenosis in patients with brain infarction, although the prevalence of renal artery stenosis was not different between males and females by ² analysis. Some investigators showed female gender as one of the predictor of significant renovascular disease in patients undergoing cardiac catheterization¹⁸ or in the general hypertensive population.²² Our findings indicated that conventional risk factors for atherosclerosis, such as hypercholesterolemia, diabetes mellitus, smoking history, and male gender, may not influence the prevalence of renal artery stenosis in patients who have an atherosclerotic lesion elsewhere. Predictors of renal artery stenosis in patients with stroke may be different from those of general population. Proteinuria, which was frequently detected in patients with renal artery stenosis, was associated with the prevalence of renal artery stenosis in patients with brain infarction.¹⁴

It has been reported that patients with stenotic extracranial carotid arteries were more likely to have renal artery stenosis. The association between renal artery and extracranial carotid artery atherosclerosis has been studied on the basis of angiography or ultrasonography. The 45% to 100% of patients with renal artery stenosis had comorbid carotid artery stenosis,^{11 23 24 25} and carotid stenosis was considered an independent predictor of renal artery stenosis in patients with aortoiliac disease.²⁶ These findings were very close to our results. Even in patients with brain infarction, extracranial carotid artery stenosis was an independent predictor of renal artery stenosis.

Some studies have indicated that the survival rate of patients with renal artery stenosis is low, and major causes of death are cardiovascular or cerebrovascular diseases rather than renal failure.^{6 7 9} High production of angiotensin II was suggested to be associated with this increased mortality. Thus, early and successful surgery or angioplasty could attenuate acceleration of atherosclerosis, in addition to stabilizing renal function and controling blood pressure. We should consider the possibility of both renal function recovery and risk associated with revascularization procedures due to comorbid atherosclerotic diseases such as ischemic heart disease and stroke. In addition, stroke patients are commonly treated with an ACE inhibitor, because this drug has been reported to have a favorable effect on cerebral blood flow autoregulation. Therefore, patients with stroke require careful monitoring of renal function when an ACE inhibitor is administered, since they may have bilateral renal artery stenosis.

In conclusion, the current autopsy study showed that the prevalence of atherosclerotic renal artery stenosis was 10.4% in patients aged 40 years with stroke and 12.1% in such patients with brain infarction. Patients with extracranial carotid artery stenosis were more likely to have renal artery stenosis. Renal insufficiency, presence of carotid artery stenosis, and hypertension were independent predictors of renal artery stenosis among autopsied patients with brain infarction.

	Acknowledgments

 
Supported by Research Grants for Cardiovascular Diseases (C-1995-3 and A-1997-9) and for Scientific Research Expenses for Health and Welfare Programs, and Funds for Comprehensive Research on Long Term Chronic Disease (Renal Failure), all from the Ministry of Health and Welfare of Japan, as well as Grants from Salt Science Research Foundation, Japan Cardiovascular Research Foundation, and Takeda Science Foundation.

	Footnotes

 
Reprint requests to Setsuko Kuroda, MD, Division of Nephrology and Cardiology, Keiaikai Minami 1-jo Hospital, S1W13 Chuo-ku, Sapporo 060-0061, Japan.

Received July 6, 1999; revision received October 26, 1999; accepted October 26, 1999.

	References

Top Abstract Introduction Methods Results Discussion References

 

1. Schwartz CJ, White TA. Stenosis of renal artery: an unselected necropsy study. BMJ. 1964;2:1415–1421.
2. Greco BA, Breyer JA. Atherosclerotic ischemic renal disease. Am J Kidney Dis. 1997;29:167–187.[Medline] [Order article via Infotrieve]
3. Olin JW, Melia M, Young JR, Graor RA, Risius B. Prevalence of atherosclerotic renal artery stenosis in patients with atherosclerosis elsewhere. Am J Med. 1990;88(1N):46N–51N.
4. Jean WJ, al-Bitar I, Zwicke DL, Port SC, Schmidt DH, Bajwa TK. High incidence of renal artery stenosis in patients with coronary artery disease. Cathet Cardiovasc Diagn. 1994;32:8–10.[Medline] [Order article via Infotrieve]
5. Zierler RE, Bergelin RO, Isaacson JA. Natural history of atherosclerotic renal artery stenosis: a prospective study with duplex ultra-sonography. J Vasc Surg. 1994;19:250–258.[Medline] [Order article via Infotrieve]
6. Baboolal K, Evans C, Moore RH. Incidence of end-stage renal disease in medically treated patients with severe bilateral atherosclerotic renovascular disease. Am J Kidney Dis. 1998;31:971–977.[Medline] [Order article via Infotrieve]
7. Mailloux LU, Napolitano B, Bellucci AG, Vernace M, Wilkes BM, Mossey RT. Renal vascular disease causing end-stage renal disease, incidence, clinical correlates, and outcomes: a 20-year clinical experience. Am J Kidney Dis. 1994;24:622–629.[Medline] [Order article via Infotrieve]
8. Appel RG, Bleyer AJ, Reavis S, Hansen KJ. Renovascular disease in older patients beginning renal replacement therapy. Kidney Int. 1995;48:171–176.[Medline] [Order article via Infotrieve]
9. Conlon PJ, Athirakul K, Kovalik E, Schwab SJ, Crowley J, Stack R, McCants CB Jr, Mark DB, Bashore TM, Albers F. Survival in renal vascular disease. J Am Soc Nephrol. 1998;9:252–256.[Abstract]
10. Textor SC. Revascularization in atherosclerotic renal artery disease. Kidney Int. 1998;53:799–811.[Medline] [Order article via Infotrieve]
11. Hansen KJ, Thomason RB, Craven TE, Fuller SB, Keith DR, Appel RG, Dean RH. Surgical management of dialysis-dependent ischemic nephropathy. J Vasc Surg. 1995;21:197–211.[Medline] [Order article via Infotrieve]
12. Harden PN, MacLeod MJ, Rodger RSC, Baxter GM, Connell JMC, Dominiczak AF, Junor BJR, Briggs JD, Moss JG. Effect of renal-artery stenting on progression of renovascular renal failure. Lancet. 1997;349:1133–1136.[Medline] [Order article via Infotrieve]
13. Blum U, Krumme B, Flugel P, Gabelmann A, Lehnert T, Buitrago-Tellez C, Schollmeyer P, Langer M. Treatment of ostial renal-artery stenoses with vascular endoprostheses after unsuccessful balloon angioplasty. N Engl J Med. 1997;336:459–465.[Abstract/Free Full Text]
14. Uzu T, Inoue T, Fujii T, Nakamura S, Inenaga T, Yutani C, Kimura G. Prevalence and predictors of renal artery stenosis in patients with myocardial infarction. Am J Kidney Dis. 1997;29:733–738.[Medline] [Order article via Infotrieve]
15. Timsit SG, Sacco RL, Mohr JP, Foulkes MA, Tatemichi TK, Wolf PA, Price TR, Hier DB. Early clinical differentiation of cerebral infarction from severe atherosclerotic stenosis and cardioembolism. Stroke. 1992;23:486–491.[Abstract/Free Full Text]
16. Handa N, Matsumoto M, Maeda H, Hongaku H, Kamada T. Ischemic stroke events and carotid atherosclerosis. Results of the Osaka Follow-up Study for Ultrasonographic Assessment of Carotid Atherosclerosis (the OSACA Study). Stroke. 1995;26:1781–1786.[Abstract/Free Full Text]
17. Nagao T, Sadoshima S, Ibayashi S, Takeya Y, Fijishima M. Increase in extracranial atherosclerotic carotid lesions in patients with brain ischemia in Japan: an angiographic study. Stroke. 1994;25:766–770.[Abstract]
18. Harding MB, Smith LR, Himmelstein SI, Harisson K, Phillips HR, Zchwab SJ, Hermiller JB, Davidson CJ, Bashore TM. Renal artery stenosis: prevalence and associated risk factors in patients undergoing routine cardiac catheterization. J Am Soc Nephrol. 1992;2:1608–1616.[Abstract]
19. Rimmer JM, Gennari FJ. Atherosclerotic renovascular disease and progressive renal failure. Ann Intern Med. 1993;118:712–719.[Abstract/Free Full Text]
20. MacDowall P, Kalra PA, O’Donoghue DJ, Waldek S, Mamtora H, Brown K. Risk of morbidity from renovascular disease in elderly patients with congestive cardiac failure. Lancet. 1998;352:13–16.[Medline] [Order article via Infotrieve]
21. Hans SS, Zeskind HJ. Routine use of limited abdominal aortography with digital subtraction carotid and cerebral angiography. Stroke. 1995;26:1221–1224.[Abstract/Free Full Text]
22. Krijnen P, van Jaarsveld BC, Steyerberg EW, Man in’t Veld AJ, Schalekamp MADH, Habbema JDF. A clinical prediction rule for renal artery stenosis. Ann Intern Med. 1998;129:705–711.[Abstract/Free Full Text]
23. Rossi GP, Rossi A, Zanin L, Calabro A, Feltrin GP, Pessina AC, Crepaldi G, Dal Palu C. Excess prevalence of extracranial carotid artery lesions in renovascular hypertension. Am J Hypertens. 1992;5:8–15.[Medline] [Order article via Infotrieve]
24. Missouris CG, Papavassiliou MB, Khaw K, Hall T, Belli AM, Buckenham T, MacGregor GA. High prevalence of carotid artery disease in patients with atheromatous renal artery stenosis. Nephrol Dial Transplant. 1998;13:945–948.[Abstract/Free Full Text]
25. Louie J, Isaacson JA, Zierler RE, Bergelin RO, Strandness DE Jr. Prevalence of carotid and lower extremity arterial disease in patients with renal artery stenosis. Am J Hypertens. 1994;7:436–439.[Medline] [Order article via Infotrieve]
26. Miralles M, Corominas A, Cotillas J, Castro F, Clara A, Vidal-Barraquer F. Screening for carotid and renal artery stenoses in patients with aortoiliac disease. Ann Vasc Surg. 1998;12:17–22.[Medline] [Order article via Infotrieve]

This article has been cited by other articles:

				G. Tsagalis, T. Akrivos, M. Alevizaki, E. Manios, K. Stamatellopoulos, A. Laggouranis, and K. N. Vemmos Renal dysfunction in acute stroke: an independent predictor of long-term all combined vascular events and overall mortality Nephrol. Dial. Transplant., August 26, 2008; (2008) gfn471v1. [Abstract] [Full Text] [PDF]

				T. K. Alphons Wierema, A. A. Kroon, and P. W. de Leeuw Poor performance of diagnostic tests for atherosclerotic renal artery stenosis--discrepancies between stenosis and renal function Nephrol. Dial. Transplant., March 1, 2007; 22(3): 689 - 692. [Full Text] [PDF]

				H. Guo, P. A. Kalra, D. T. Gilbertson, J. Liu, S.-C. Chen, A. J. Collins, and R. N. Foley Atherosclerotic Renovascular Disease in Older US Patients Starting Dialysis, 1996 to 2001 Circulation, January 2, 2007; 115(1): 50 - 58. [Abstract] [Full Text] [PDF]

				M. A Allison, D. DiTomasso, M. H Criqui, R. D Langer, and C M. Wright Renal artery calcium: relationship to systemic calcified atherosclerosis Vascular Medicine, November 1, 2006; 11(4): 232 - 238. [Abstract] [PDF]

				M. Chonchol and S. Linas Diagnosis and Management of Ischemic Nephropathy Clin. J. Am. Soc. Nephrol., March 1, 2006; 1(2): 172 - 181. [Full Text] [PDF]

				H. Fujii, S. Nakamura, S. Kuroda, F. Yoshihara, H. Nakahama, T. Inenaga, H. Ueda-Ishibashi, C. Yutani, and Y. Kawano Relationship between renal artery stenosis and intrarenal damage in autopsy subjects with stroke Nephrol. Dial. Transplant., January 1, 2006; 21(1): 113 - 119. [Abstract] [Full Text] [PDF]

				C. M. Cheung, J. Hegarty, and P. A. Kalra Dilemmas in the management of renal artery stenosis Br. Med. Bull., September 7, 2005; 73-74(1): 35 - 55. [Abstract] [Full Text] [PDF]

				R. de Silva, N. P. Nikitin, S. Bhandari, A. Nicholson, A. L. Clark, and J. G.F. Cleland Atherosclerotic renovascular disease in chronic heart failure: should we intervene? Eur. Heart J., August 2, 2005; 26(16): 1596 - 1605. [Abstract] [Full Text] [PDF]

				R. C. Pasternak, M. H. Criqui, E. J. Benjamin, F. G. R. Fowkes, E. M. Isselbacher, P. A. McCullough, P. A. Wolf, and Z.-J. Zheng Atherosclerotic Vascular Disease Conference: Writing Group I: Epidemiology Circulation, June 1, 2004; 109(21): 2605 - 2612. [Full Text] [PDF]

				C. E. Buller, J. G. Nogareda, K. Ramanathan, D. R. Ricci, O. Djurdjev, K. J. Tinckam, I. M. Penn, R. S. Fox, L. A. Stevens, J. A. Duncan, et al. The profile of cardiac patients with renal artery stenosis J. Am. Coll. Cardiol., May 5, 2004; 43(9): 1606 - 1613. [Abstract] [Full Text] [PDF]

				P.-F. PLOUIN, P. ROSSIGNOL, and G. BOBRIE Atherosclerotic Renal Artery Stenosis: To Treat Conservatively, to Dilate, to Stent, or to Operate? J. Am. Soc. Nephrol., October 1, 2001; 12(10): 2190 - 2196. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kuroda, S. Articles by Kimura, G. Search for Related Content PubMed PubMed Citation Articles by Kuroda, S. Articles by Kimura, G. Pubmed/NCBI databases Medline Plus Health Information Stroke