https://orcid.org/0000-0001-6492-9132
Figures
Abstract
Objective
To investigate the clinical features, diagnostic approaches, and treatment strategies of spontaneous renal artery dissection (SRAD) through systematic review and data analysis, thereby providing evidence-based insights for optimizing clinical management.
Methods
A systematic search was conducted across PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), and Wanfang Database. Case-control studies, cohort studies, and case series were included. Demographic data, symptomatology, diagnostic modalities, treatment regimens, and clinical outcomes were extracted. Statistical analyses were performed using RStudio.
Results
A total of 73 case reports involving 97 patients were included. The mean patient age was 46 years, with a male predominance (82.5%, 80/97). The most common presenting symptom was acute-onset flank pain (74.2%), and comorbid hypertension was observed in 61.9% of cases. Computed tomography angiography (CTA) was the primary diagnostic modality (85.6%), with multimodal imaging utilized in 87.6% of cases. Revascularization rates differed significantly between conservative management (37.1%), endovascular intervention (71.0%), and surgical intervention (6.2%) (P < 0.01). Regarding blood pressure outcomes: the proportion of patients achieving normotension without medication was significantly higher in the non-conservative group (54.1%, 20/37) than in the conservative group (30.0%, 6/20) (P < 0.05); however, there was no statistically significant disparity in the overall blood pressure control rate (normotension without medication + controlled with medication) between groups (P > 0.05). Overall mortality was 3.1%, and renal function deterioration occurred in 30.9% of patients.
Conclusion
Management of SRAD necessitates individualized decision-making. Conservative therapy remains appropriate for most patients, while endovascular intervention demonstrates superior revascularization efficacy in cases with severe symptomatology or dissection progression. Prospective studies are warranted to validate therapeutic disparities and establish standardized diagnostic and treatment protocols.
Citation: Zhu J, Xu Z, Geng Y, Jiang M, Xu C, Xu Y (2026) Clinical characteristics, diagnostic modalities, and therapeutic strategies of spontaneous renal artery dissection: A systematic review and diagnostic analysis. PLoS One 21(1): e0340766. https://doi.org/10.1371/journal.pone.0340766
Editor: Chiara Lazzeri, Azienda Ospedaliero Universitaria Careggi, ITALY
Received: May 21, 2025; Accepted: December 26, 2025; Published: January 23, 2026
Copyright: © 2026 Zhu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
1. Introduction
Spontaneous renal artery dissection (SRAD) is a rare non-traumatic vascular disorder (annual incidence: 0.5–1.5 per 100,000; 1%–2% of renal artery pathologies) characterized by spontaneous renal artery intimal tear, false lumen formation, and potential complications including renal ischemia, infarction, or irreversible impairment [1,2]. Key pathogenic factors include arterial medial degeneration, hypertension, fibromuscular dysplasia (FMD), and hereditary vasculopathies [1,3]. Its clinically insidious presentation and overlap with common acute abdominal conditions (e.g., nephrolithiasis, pyelonephritis) lead to underdiagnosis rates exceeding 30%, even with advancements in non-invasive imaging (CTA, MRA) [4,5].
Clinical management of SRAD is hindered by two critical gaps: (1) reliance on small-sample case reports/retrospective studies (no large-scale RCTs or cohort studies) leading to controversy over optimal therapies (conservative, endovascular, open surgery); and (2) heterogeneous outcome assessment criteria (e.g., blood pressure normalization, revascularization success) that impede unified efficacy evaluation [5]. Discrepancies in study findings—e.g., conflicting support for early endovascular intervention vs. conservative management in stable patients—undermine evidence-based decision-making and standardized guideline development.
To address these gaps, this study conducted a systematic review of global SRAD case reports and cohort studies published between 1991 and 2024, pooling clinical data from 97 patients. The objectives are threefold: (1) to comprehensively delineate the epidemiological profile, clinical manifestations, and imaging-based diagnostic patterns of SRAD; (2) to compare the efficacy of diverse therapeutic strategies (conservative, endovascular, surgical) in achieving revascularization, blood pressure control, and renal function preservation; and (3) to evaluate complication rates and prognostic risks, thereby generating evidence-based recommendations for individualized management. The findings aim to address current evidence gaps, facilitating a paradigm shift from empirical to evidence-based management of SRAD and ultimately improving long-term patient outcomes.
2. Materials and methods
Ethical approval for this study was provided by the Ethics Committee of the Affiliated Hospital of Binzhou Medical College.
2.1. Literature search and screening
This systematic review adhered to the Preferred Reporting Items for Systematic Reviews guidelines.
A comprehensive search was conducted in PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), and Wanfang Database for case-control studies, cohort studies, and case series on spontaneous renal artery dissection (SRAD), with the search period spanning from database inception to December 2024. English search terms included: spontaneous renal artery dissection, SRAD, non-traumatic renal artery dissection, diagnosis, treatment, prognosis, and outcomes. Chinese search terms comprised: zi fa xing shen dong mai jia ceng, fei chuang shang xingshen dong mai jia ceng, zhen duan and yu hou. The search strategy combined Medical Subject Headings (MeSH) terms with free-text keywords. Manual screening of reference lists from included studies and authoritative journals in nephrology (e.g., Journal of Vascular Surgery, Nephrology) was performed to ensure comprehensiveness. Two investigators (JZ and ZX) independently conducted the manual search to verify completeness and accuracy. The PubMed search strategy is detailed in Fig 1.
2.2. Inclusion and exclusion criteria
2.2.1. Study types.
Case-control studies, cohort studies, and case series were included. Conference abstracts and studies lacking control groups (except for prognostic analyses) were excluded.
2.2.2. Interventions.
Studies comparing diagnostic accuracy across imaging modalities (e.g., CTA, MRA, DSA) or therapeutic efficacy between conservative management (anticoagulation/antihypertensive therapy), endovascular intervention (stent placement/angioplasty), and open surgery were included.
2.2.3. Participants.
Patients with SRAD confirmed by imaging (CTA/MRA/DSA) or histopathology, without a history of trauma or iatrogenic causes.
2.2.4. Outcome measures.
Blood pressure recovery: Normalized (without medication), partially controlled (requiring medication), or uncontrolled.
Revascularization success or failure.
Renal function: Stabilized (serum creatinine fluctuation <20%), improved (serum creatinine reduction >20%), or deteriorated (serum creatinine elevation >20%).
Survival: Alive (follow-up ≥3 months) or deceased.
2.2.5. Exclusion criteria.
A. Reviews or conference abstracts; B. Duplicate publications; C. Animal experiments or cellular studies; D. Studies with duplicated data or insufficient extractable key information; E. Cases of renal artery dissection secondary to vascular interventions, trauma, or extensive aortic/visceral/mesenteric artery dissections.
2.3. Literature screening and data extraction
Two investigators independently extracted the following data:
- a. Study characteristics: Title, first author, study design, journal, publication year.
- b. Baseline patient data: Sample size, demographics (age, sex, comorbidities), symptoms (flank pain, hypertension, renal dysfunction).
- c. Key risk-of-bias elements.
- d. Outcomes: Diagnostic modalities (CTA/MRA/DSA), treatment strategies (conservative, endovascular, surgical repair), and outcomes (revascularization, therapeutic efficacy, complications, follow-up). Discrepancies were resolved through consensus discussions.
2.4. Quality appraisal and risk of bias assessment
The methodological quality of the 73 included studies was evaluated using the CARE (Case Report) guidelines and Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Reports. Two independent reviewers conducted the quality assessment, with disagreements resolved via consensus.
3. Results
3.1. Literature search results
The initial search yielded 551 potentially relevant articles, including 141 from PubMed, 43 from Cochrane Library, 4 from Embase, 163 from Web of Science, 138 from China National Knowledge Infrastructure (CNKI), and 50 from Wanfang Database. After deduplication, 335 articles underwent title and abstract screening, with 198 excluded due to insufficient data or mismatched study types. Full-text review of 137 articles led to the inclusion of 73 case reports involving 97 patients with spontaneous renal artery dissection (SRAD). The screening flowchart is illustrated in Fig 2.
3.2. Quality appraisal and risk of bias assessment
Methodological quality of the 73 studies was assessed using the CARE guidelines and Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Reports. A summary table of quality evaluation results and risk assessment of bias is shown in Table 1. Two independent reviewers achieved substantial agreement (Kappa = 0.72), with discrepancies resolved via consensus.
Quality tiers were defined as follows
High quality (CARE score ≥10 + JBI score ≥6 + custom criteria ≥2): 18 studies (24.7%), characterized by robust imaging evidence (CTA + DSA), follow-up ≥6 months, and detailed therapeutic protocols.
Moderate quality (CARE 7–9 + JBI 4–5 + custom criteria ≥1): 31 studies (42.5%), with limitations including incomplete data (e.g., smoking history omission) and short follow-up (3 months).
Low quality (CARE ≤6 + JBI ≤ 3 + custom criteria ≤1): 24 studies (32.8%), marked by failure to exclude secondary causes, reliance on single imaging modality (e.g., ultrasound only), and vague outcome descriptions.
Risk of bias was stratified as
Low risk (22 studies, 30.1%): Adequate control of selection bias (exclusion of secondary causes), information bias (gold-standard imaging + complete follow-up), and confounding factors (e.g., comorbidity adjustment).
Moderate risk (35 studies, 47.9%): Partial adherence to quality criteria without critical flaws.
High risk (16 studies, 21.9%): Major deficiencies, including key data gaps (e.g., survival bias) or reliance on single diagnostic modality.
Key limitations included short-term follow-up (28.8%), inadequate confounding control (41.1%), and non-multimodal imaging (19.2%).
3.3. Baseline characteristics of included studies
Studies spanned 1991–2024 (Table 2, Table 3). The cohort comprised 97 patients (mean age 47.6 ± 11.3 years; median 46 years), with male predominance (82.5%, 80/97). Hypertension was present in 61.9% (60/97) at onset, with 23 cases reporting specific blood pressure values (mean systolic 167 ± 24 mmHg, diastolic 98 ± 18 mmHg). Smoking history was noted in 18.6% (18/97). Comorbidities included preexisting hypertension (11.3%, 11/97), fibromuscular dysplasia (FMD, 16.5%, 16/97), diabetes mellitus (2.1%, 2/97), and cardiovascular disease (e.g., coronary artery disease, 7.2%, 7/97). Presenting symptoms included acute-onset flank pain (74.2%, 72/97), hematuria (13.4%, 13/97), and hypertensive crisis (16.5%, 16/97). Diagnostic delay occurred in 8.2% (8/97), with misdiagnoses as nephrolithiasis (3 cases), pyelonephritis (6 cases), or renal vein thrombosis (1 case).
3.4. Diagnostic modalities
Computed tomography angiography (CTA) was the most utilized imaging modality (85.6%, 83/97), followed by digital subtraction angiography (DSA, 36.1%, 35/97), ultrasonography (14.4%, 14/97), and magnetic resonance imaging/angiography (MRI/MRA, 12.4%, 12/97). Multimodal imaging (≥2 modalities) was employed in 87.6% (85/97), most commonly CTA + DSA (19.6%, 19/97). Unilateral renal artery involvement occurred in 64.9% (63/97), with right (46.0%, 29/63) and left (54.0%, 34/63) arteries affected. Bilateral or multivessel dissection accounted for 35.1% (34/97).
3.5. Treatment strategies
Conservative management (36.1%, 35/97): Antihypertensive therapy (ACEI/ARB), anticoagulation (low-molecular-weight heparin), and serial imaging surveillance.
Endovascular intervention (57.7%, 56/97): Stent placement, thrombectomy, or angioplasty.
Surgical repair (6.2%, 6/97): Open surgical repair, nephrectomy, or vascular reconstruction.
3.6. Outcome measures
3.6.1. Blood pressure recovery and renal function.
A total of 60 patients had complete blood pressure follow-up data (3 cases were excluded due to incomplete monitoring records: 1 lost to follow-up, 2 with irregular medication and blood pressure documentation). Overall, 96.7% (58/60) achieved blood pressure control (normotension without medication + controlled with medication). Subgroup analysis showed that the proportion of normotension without medication was significantly higher in the non-conservative group (54.1%, 20/37) than in the conservative group (30.0%, 6/20) (P < 0.05). Renal function stabilized or improved in 69.1% (67/97), while 30.9% (30/97) experienced deterioration or partial renal infarction.
3.6.2. Revascularization and survival.
Revascularization rates were 37.1% (13/35) for conservative management (including 5.7% spontaneous recanalization) versus 71.0% (44/62) for interventional/surgical approaches (P < 0.01). Overall mortality was 3.1% (3/97), attributed to acute renal failure and multiorgan dysfunction.
3.6.3. Complications, recurrence, and De Novo Dissection.
Postprocedural complications (limited to patients receiving endovascular or surgical intervention, n = 62) occurred in 29.0% (18/62), including endoleak (2 cases), acute kidney injury (7 cases), and access site hematoma (1 case). Recurrent or de novo dissection developed in 3 cases (3.1% of total patients): 2 recurrent cases in the endovascular intervention group (follow-up 6 and 12 months, respectively) and 1 de novo dissection in the conservative management group (follow-up 18 months, involving the contralateral renal artery).
4. Data analysis
4.1. Impact of treatment strategy on revascularization
A total of 97 SRAD patients from 73 studies were stratified by treatment strategy. The conservative management group (n = 35) achieved revascularization in 13 cases (37.1%) versus 22 failures (62.9%). In the non-conservative group (n = 62), revascularization succeeded in 44 cases (71.0%) versus 18 failures (29.0%). Risk ratio (RR) analysis demonstrated that conservative management was associated with a 0.52-fold lower likelihood of revascularization success compared to non-conservative strategies (RR = 0.52, 95% CI [0.29–0.74]). Odds ratio (OR) analysis further indicated that conservative management was associated with a 75.8% reduction in the odds of revascularization (OR=0.242, 95% CI [0.1–0.58]).
Chi-square testing revealed a statistically significant disparity in revascularization rates between groups (χ² = 9.2128, df = 1, P = 0.0024; P < 0.01). The effect size of treatment strategy on revascularization outcomes is illustrated in Fig 3.
4.2. Impact of treatment strategy on blood pressure recovery
Among 57 patients with complete subgroup blood pressure data (excluding 3 cases with incomplete records), blood pressure outcomes were categorized as normotension without medication or controlled with medication. In the conservative group (n = 20), 6 patients (30.0%) achieved normotension without medication versus 14 (70.0%) requiring medication. In the non-conservative group (n = 37), 20 (54.1%) achieved normotension without medication versus 17 (45.9%) controlled with medication. RR analysis suggested conservative management was associated with a 0.66-fold lower probability of blood pressure normalization without medication (RR = 0.52, 95% CI [0.42–1.03]). OR analysis indicated conservative strategies were associated with a 64.0% reduction in the odds of medication-free normalization (OR=0.36, 95% CI [0.11–1.16]).
Chi-square testing showed no statistically significant association between treatment strategy and overall blood pressure control rate (normotension without medication + controlled with medication) (χ² = 2.1359, df = 1, P = 0.1439; P > 0.05). The effect size of treatment strategy on blood pressure outcomes is detailed in Fig 4.
5. Discussion
Spontaneous renal artery dissection (SRAD), a rare non-traumatic vascular pathology, necessitates precise diagnostic and therapeutic decision-making to optimize patient outcomes. This study synthesizes data from 73 global publications to delineate SRAD’s epidemiological profile and clinical management. Our findings confirm prior reports of a middle-aged male predilection (mean age 46 years), likely due to higher hypertension and arteriosclerosis prevalence in this group. While acute-onset flank pain is the hallmark symptom, the observed 8.2% misdiagnosis rate—often misattributed to nephrolithiasis or pyelonephritis—underscores the imperative for heightened clinical vigilance in differential diagnosis [6]. Consistent with prior studies [1,3,5], our systematic review of 97 patients confirms a predilection for middle-aged males (mean age 46 years), with hypertension (61.9%) and acute-onset flank pain (74.2%) as the most common comorbidity and presenting symptom, respectively. Antopolsky et al. [1] reported similar demographic and clinical features in their 10-year ED study, while Yoon et al.[3] emphasized the role of hypertension and FMD in SRAD pathogenesis—findings that align with our comorbidity data (FMD in 16.5% of cases). Notably, the 8.2% misdiagnosis rate observed in our study (mostly as nephrolithiasis or pyelonephritis) echoes Jha et al.’s [5] systematic review (underdiagnosis rate >30%), underscoring the need for heightened clinical vigilance in differential diagnosis. Our study extends previous research by providing detailed subgroup analysis of blood pressure outcomes and recurrence risk, which were not fully addressed in Jha et al.’s [5] review.
Multimodal imaging protocols, particularly the integration of CTA and DSA, show complementary clinical value in SRAD diagnosis. CTA, with its superior spatial resolution and rapid acquisition, facilitates accurate delineation of dissection morphology (e.g., intimal tear location, false lumen extent), which is consistent with its role as the first-line imaging modality reported in 85.6% of our cases. DSA, as the gold standard for hemodynamic assessment, retains irreplaceable value in evaluating stenosis severity and collateral circulation—critical for guiding interventional therapy [1]. While our study did not perform head-to-head diagnostic efficacy comparisons, the high utilization rate of multimodal imaging (87.6%) in clinical practice reflects its practical utility in comprehensive evaluation. This aligns with clinical consensus that no single modality can address all diagnostic needs, and a stepwise algorithm combining CTA and DSA balances anatomical visualization and functional assessment.
Therapeutic strategy selection must be individualized based on symptom acuity, dissection progression, and renal functional reserve. Conservative management (antihypertensive/anticoagulant therapy) is suitable for hemodynamically stable patients without significant renal impairment [7,8], though its inferior revascularization efficacy (37.1% vs. 71.0% for interventional strategies) supports prioritizing endovascular intervention in symptomatic or radiographically progressive cases. It is important to note that these pooled estimates (RR, OR) are subject to inherent biases of case report data—including publication bias (successful interventional cases may be overrepresented) and selection bias (patients with milder symptoms may be more likely to undergo conservative management and underreported). Thus, the comparative efficacy of treatment strategies should be interpreted with caution, and these findings do not constitute definitive causal evidence. Proactive vascular repair may improve long-term outcomes in anatomically suitable lesions, but procedural risks (29.0% complication rate in the intervention group: endoleak, acute kidney injury, etc.) require careful risk-benefit assessment—particularly in elderly or high-comorbidity patients.
This analysis is constrained by several methodological factors: (1) reliance on retrospective case reports with inherent selection and reporting biases; (2) data heterogeneity, including incomplete documentation of smoking history and long-term follow-up; (3) the absence of randomized controlled trials (RCTs) to validate therapeutic disparities. (4) the inability to apply advanced meta-analytic techniques (e.g., meta-regression, sensitivity analysis) due to the inherent limitations of case report data—including lack of control groups, high clinical heterogeneity, and lack of prospective data collection.
These advanced methods are typically used to explore moderating variables or assess the robustness of pooled results, but their application here is methodologically unfeasible, further restricting causal inference from the pooled risk ratios (RR) and odds ratios (OR). It is important to note that these associations may be influenced by indication bias—patients with more severe symptoms or anatomical lesions are more likely to undergo interventional treatment—limiting causal inference.
Future multicenter prospective cohorts should establish standardized risk stratification frameworks, incorporating advanced imaging biomarkers and molecular profiling to guide individualized therapeutic algorithms.
6. Conclusion
The management of spontaneous renal artery dissection (SRAD) requires dynamic adjustment tailored to individual clinical characteristics and radiographic progression. While conservative therapy may serve as an initial strategy for hemodynamically stable patients, endovascular intervention demonstrates superior efficacy in achieving revascularization and should be prioritized in cases of symptomatic or anatomical deterioration. Clinicians must emphasize multimodal imaging integration to prevent diagnostic oversights and misclassification. Future research should focus on optimizing therapeutic timing, mitigating complication risks, and establishing evidence-based guidelines through randomized controlled trials (RCTs), ultimately improving long-term prognoses for SRAD patients.
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