We investigated the prevalence of renal artery disease and outcome in a cohort of atherosclerotic patients with renal dysfunction. We studied 44 consecutive patients who were older than 50 years of age, who had renal dysfunction and in whom one or more of the following atherosclerotic diseases was confirmed: cerebral infarction, coronary artery disease or peripheral vascular disease. Renal artery stenosis was assessed by gadolinium-enhanced magnetic-resonance angiography. Patients who were treated medically were prospectively followed up in our outpatient clinic and the impact of renal artery stenosis on survival was evaluated. Renal artery stenosis was found in 22 (50%) of the 44 patients. Difference in kidney length and carotid artery stenosis were identified as independent predictors of renal artery stenosis. Among the patients who were treated medically (n =42), rates of mortality were 4.4, 12.7 and 18.1 per 100 patient-years in those without renal artery stenosis, those with unilateral renal artery stenosis and those with bilateral renal artery stenosis, respectively. The mortality and renal survival curves were significantly different among these three groups. These findings indicate that renal artery stenosis is common in patients with renal dysfunction and concomitant cardiovascular disease, especially in those with carotid artery stenosis, and that a substantial difference in the length of kidneys may be a predictor of renovascular disease. Patients with renal dysfunction resulting from renal artery stenosis are at risk of death from cardiovascular disease and end-stage renal failure. (Hypertens Res 2002; 25: 537-542)