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and endovascular intervention is a viable option, renal arteriography, the definitive diagnostic test, is the best approach Renal arteriography is not recommended as a routine adjunct to coronary studies Where suspicion is moderate to low, noninvasive angiography using magnetic resonance (MR) or CT are reasonable approaches With improvements in technology, Doppler sonography may play an increasing role in detection of RAS, providing physiologic indices of stenosis severity and ease of repeated examination to detect progression However, results of all these modalities vary greatly between institutions In 2006, a public health advisory was issued regarding the use of gadolinium (a contrast agent used in MRA), warning that it might precipitate nephrogenic systemic fibrosis in patients with advanced renal failure Clearly, no diagnostic study should be undertaken without a careful consideration of the risk-benefit ratio In young patients with fibromuscular disease, angioplasty is very effective, but there is a great deal of controversy regarding the best approach to the treatment of atheromatous renal artery stenosis Surgical correction of the lesion in selected patients might reduce the number of medications required to control blood pressure and could protect renal function, but the extent of preexisting parenchymal damage to the affected and contralateral kidney has the greatest influence on blood pressure and renal function outcomes following revascularization A reasonable approach advocates medical therapy as long as hypertension can be well controlled and there is no progression of renal insufficiency Endovascular intervention might be considered in patients with uncontrollable hypertension, progressive renal failure, or episodic pulmonary edema attributable to the lesion Angioplasty might also be warranted when progression of stenosis is either demonstrated or is predicted by a constellation of risk factors, including systolic blood pressure > 160 mm Hg, advanced age, diabetes mellitus, and high-grade stenosis (> 60%) at the time of diagnosis Although ACE inhibitors have improved the success rate of medical therapy of hypertension due to renal artery stenosis, they have been associated with marked hypotension and (usually reversible) renal dysfunction in individuals with bilateral disease Thus, renal function and blood pressure should be closely monitored during the first weeks of therapy in patients in whom this is a consideration 4 Primary hyperaldosteronism Primary hyperaldosteronism occurs because of excessive secretion of aldosterone by the adrenal cortex It may, in fact, be the most common potentially curable and specifically treatable cause of hypertension In the past, the diagnosis was suspected in hypertensive patients who exhibited hypokalemia, excessive urinary potassium excretion (usually > 40 mEq/L on a spot specimen), and suppressed levels of plasma renin activity However, the development and application of new screening tests to the population of hypertensive persons have resulted in a marked increase in the detection rate for primary hyperaldosteronism It now appears that up to 5 15% of patients in whom primary (essential) hypertension is diagnosed actually have primary hyperaldosteronism, with most having normal serum potassium levels Currently, the best screening test for primary hyperaldosteronism involves determinations of plasma aldosterone concentration (nor-.

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