Purpose of review: Atherosclerotic renovascular disease remains highly prevalent and presents an array of clinical syndromes. Recent prospective trials have dampened enthusiasm for revascularization generally, but clinicians recognize the need to identify patients likely to benefit from vascular intervention.
Recent findings: This article highlights the inflammatory nature of vascular occlusive disease and the limits of the kidney to adapt to reduced blood flow. Although moderate reductions can be tolerated, severe impairment of renal perfusion leads to tissue hypoxia and activates inflammatory injury within the kidney. Hence, assessment of kidney viability and potential tools to modify mitochondrial and inflammatory damage may be important to identify patients for whom clinical intervention should be undertaken.
Summary: Clinicians must recognize clinical syndromes that identify 'high-risk' groups and apply revascularization in those likely to benefit. Future efforts to protect the kidney (e.g., mitochondrial protection) or cell-based therapy may amplify clinical recovery when combined with restoring renal blood flow.