The impact of atherosclerotic renovascular disease on diabetic renal failure

Atherosclerotic renovascular disease (ARVD) is common in thegeneral population, and its prevalence increases with age. Parallelstudies show it is also common in patients with diabetes. The widespreaduse of angiotensin converting enzyme inhibitors and angiotensin receptorantagonists for heart and kidney disease might therefore expose arteriopathicdiabetic patients to potential harm if they had critical renal arterystenosis. This review looks at the natural history of ARVD in thediabetic and non‐diabetic populations: while it is common, it only rarelyleads to renal failure. Hence intervention to revascularize ischaemic kidneyson the basis of radiological appearances alone may subject somepatients to unnecessary therapy. Although untested by randomizedtrial, a policy of watchful waiting may be the simplest strategyfor most diabetic patients with suspected ARVD, reserving angiography andangioplasty (usually backed up by a stent) for those with an abruptdecline in renal function and no other cause for renal deterioration. Futureclinical trials may better define subgroups of patients who will trulybenefit from renal revascularization.