11 Flash pulmonary oedema (FPE) is probably the most widely accepted indication for renal revascularization. Cardiac dysfunction and ARVD go hand in hand, which, coupled with other factors, predisposes to FPE. Renal artery constriction can cause hypertension mediated predominantly by the renin-angiotensin-aldosterone system (RAAS).41 A normally functioning contralateral kidney can Navitoclax respond to increased RAAS activity on the affected side by suppression of its own renin secretion to help prevent

volume overload. Should both kidneys be affected by RAS then this homeostatic safety valve will not function leading to higher risk of volume overload. Neurohormonal mediated endothelial dysfunction brought about by PD-0332991 nmr excess stimulation of the RAAS causes increased pulmonary capillary permeability and further contributes towards FPE.42 Additionally, CKD is associated with increased arterial stiffness,43 concentric left ventricular hypertrophy,44 and increased left ventricular stiffness.45 This triad makes the circulatory system exquisitely sensitive to alterations in volume state, with little physiological reserve to deal with volume expansion. In the setting of FPE, ARVD is, predictably, often bilateral or present in a solitary functioning kidney. Although there are no

randomized or observational studies, revascularization has been shown to be of benefit in small series and case reports,46,47 with a suggestion that those with bilateral disease are most likely to benefit.48 Resistant hypertension (RH), defined as uncontrolled blood pressure (>160/90 mmHg) despite use of three or more

antihypertensive medications, is an area of ongoing debate. Therapeutic measures to treat hypertension have evolved rapidly over the years, and many drug therapies are applicable in patients with ARVD. Given the relationship between untreated hypertension and deterioration of renal function, effective treatment is paramount. While previously nephrectomies of ischaemic kidneys were undertaken to treat ‘malignant’ hypertension,49 with the Cyclin-dependent kinase 3 advent of antihypertensives targeted to block the RAAS, and percutaneous revascularization techniques, this approach is now no longer applicable. Despite these pharmacological advances, there is often reticence to use angiotensin converting enzyme inhibitors (ACEi) and receptor blockers (ARB). These are very effective treatments for renovascular driven hypertension but there are widely held beliefs that bilateral RAS is a contra-indication for their use. Although it is beyond dispute that ACEi or ARB use can reduce GFR in certain individuals, patients with unilateral disease and a normally functioning contralateral kidney do not usually suffer this fate.50 Indeed, our experience is that many patients with significant bilateral RAS can tolerate RAAS blockade without detriment to function.