In a patient suspected to have atherosclerosis, resistant hypertension and a drop in the predicted glomerular filtration rate (eGFR) are three elements that are very critical for increasing the presumption of atherosclerotic renal artery stenosis. Other factors, such as hypertension at an early age or malignant hypertension, play a major role as well.

According to the KDOQI Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease^[1], the most important clinical clues that should raise the suspicion of renal artery disease are the triad:

• Resistant Hypertension
• Reduced in estimated glomerular Filtration rate (eGFR)
• Known generalized atherosclerosis

Additional clinical clues that suggest renal artery disease are listed below^[1]:

• Age of hypertension < 30 years and > 55 years
• Abrupt onset of hypertension
• Accelerated hypertension that was previously well-controlled
• Refractory hypertension to 3 anti-hypertensive medications
• Malignant hypertension
• Smoking
• Abdominal bruit
• Flash pulmonary edema
• Generalized atherosclerosis obliterans
• Asymmetric kidney sizes
• Acute kidney injury when ACE-I or ARB are used for treatment