What is a definitive treatment for bilateral renal artery stenosis causing ACE inhibitor–induced AKI?

• A. Stop ACE inhibitors and switch to ARB
• B. Start dialysis
• C. Continue ACE inhibitors
• D. Angioplasty or stenting

Answer: (D)

In renal artery stenosis, especially when both kidneys are affected, the kidney relies on angiotensin II to constrict the efferent arteriole and maintain glomerular filtration pressure. An ACE inhibitor blocks the formation of angiotensin II, causing dilation of the efferent arteriole, drop in intraglomerular pressure, and can precipitate AKI. The definitive way to restore renal perfusion and stabilize GFR is to relieve the stenosis with endovascular revascularization—angioplasty or stenting.

Stopping ACE inhibitors or switching to an ARB may prevent further AKI but does not address the narrowed artery itself. Starting dialysis would be a treatment for established kidney failure, not a cure for the underlying stenosis. Continuing the ACE inhibitor would likely worsen the AKI. Therefore, revascularization to correct the stenosis is the most definitive therapy.