Atherosclerotic renal artery stenosis: overtreated but underrated?

Despite evidence of only moderate clinical benefit, application of renal endovascular stent procedures has increased at least four-fold in the past decade. Medicare is reviewing national coverage regarding reimbursement, questioning whether outcome data warrant many of these procedures. Several prospective, randomized trials are now in progress to compare outcomes with optimized medical therapy with and without stenting. Current imaging methods establish primarily the presence and severity of vascular occlusive disease. Optimal treatment for individual patients remains in flux and is reviewed here. Most important, nephrologists await development of tools to predict reliably when renal parenchymal injury is beyond recovery and/or when revascularization can produce meaningful salvage of kidney function.