551
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Chrysant SG, Chrysant GS. Treatment of hypertension in patients with renal artery stenosis due to fibromuscular dysplasia of the renal arteries. Cardiovasc Diagn Ther 2014; 4:36-43. [PMID: 24649423 DOI: 10.3978/j.issn.2223-3652.2014.02.01] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Accepted: 01/27/2014] [Indexed: 11/14/2022]
Abstract
Renal artery stenosis (RAS) from fibromuscular dysplasia (FMD) is an uncommon cause of hypertension that affects mostly women. FMD is a noninflammatory vascular disease that predominantly affects mainly the renal arteries, but can also affect arteries in other vascular territories. The most common type of FMD is the media fibroplasia with the characteristic "string of beads" appearance (80-90%), whereas the two other types, the "intimal" and "adventitial" FMD are much less common accounting for 10% and <5% of cases, respectively. The prevalence of FMD in the general population is not well known. Estimates are derived from screening kidney donors, with a prevalence of about 2.6%. Among patients with renovascular hypertension (RVH), its incidence is about 10%, whereas 80-90% of RVH is due to atherosclerotic renal artery stenosis (ARAS). The treatment of choice of hypertension due to FMD is percutaneous renal angioplasty (PTRA). In contrast, hypertension due to ARAS is not frequently responsive to PTRA. In order to achieve successful control of hypertension in patients with FMD, a combination of PTRA with drugs that block the renin-angiotensin-aldosterone system (RAAS) is often necessary. The purpose of this review was to search the literature for newer diagnostic methods and treatment of FMD. Therefore, a Medline search of the English literature of published papers between 2008 and December 2013 was performed. Of 58 papers reviewed, 19 pertinent papers were selected including, studies, reviews, registries and case reports. The information from these studies together with collateral literature will be discussed in this concise review.
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Affiliation(s)
- Steven G Chrysant
- 1 University of Oklahoma College of Medicine, 2 INTEGRIS Baptist Medical Center, Oklahoma City, OK, USA
| | - George S Chrysant
- 1 University of Oklahoma College of Medicine, 2 INTEGRIS Baptist Medical Center, Oklahoma City, OK, USA
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552
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Pliquett RU, Benkhoff S, Jung O, Brandes RP. Sympathoactivation and rho-kinase-dependent baroreflex function in experimental renovascular hypertension with reduced kidney mass. BMC PHYSIOLOGY 2014; 14:4. [PMID: 24946879 PMCID: PMC4074138 DOI: 10.1186/1472-6793-14-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 06/13/2014] [Indexed: 01/11/2023]
Abstract
BACKGROUND Dysregulation of the autonomic nervous system is frequent in subjects with cardiovascular disease. The contribution of different forms of renovascular hypertension and the mechanisms contributing to autonomic dysfunction in hypertension are incompletely understood. Here, murine models of renovascular hypertension with preserved (2-kidneys-1 clip, 2K1C) and reduced (1-kidney-1 clip, 1K1C) kidney mass were studied with regard to autonomic nervous system regulation (sympathetic tone: power-spectral analysis of systolic blood pressure; parasympathetic tone: power-spectral analysis of heart rate) and baroreflex sensitivity of heart rate by spontaneous, concomitant changes of systolic blood pressure and pulse interval. Involvement of the renin-angiotensin system and the rho-kinase pathway were determined by application of inhibitors. RESULTS C57BL6N mice (6 to 11) with reduced kidney mass (1K1C) or with preserved kidney mass (2K1C) developed a similar degree of hypertension. In comparison to control mice, both models presented with a significantly increased sympathetic tone and lower baroreflex sensitivity of heart rate. However, only 2K1C animals had a lower parasympathetic tone, whereas urinary norepinephrine excretion was reduced in the 1K1C model. Rho kinase inhibition given to a subset of 1K1C and 2K1C animals improved baroreflex sensitivity of heart rate selectively in the 1K1C model. Rho kinase inhibition had no additional effects on autonomic nervous system in either model of renovascular hypertension and did not change the blood pressure. Blockade of AT1 receptors (in 2K1C animals) normalized the sympathetic tone, decreased resting heart rate, improved baroreflex sensitivity of heart rate and parasympathetic tone. CONCLUSIONS Regardless of residual renal mass, blood pressure and sympathetic tone are increased, whereas baroreflex sensitivity is depressed in murine models of renovascular hypertension. Reduced norepinephrine excretion and/or degradation might contribute to sympathoactivation in renovascular hypertension with reduced renal mass (1K1C). Overall, the study helps to direct research to optimize medical therapy of hypertension.
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Affiliation(s)
- Rainer U Pliquett
- Institute for Cardiovascular Physiology, Vascular Research Centre, Fachbereich Medizin, Goethe University, Frankfurt (Main), Germany.
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553
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Eirin A, Ebrahimi B, Zhang X, Zhu XY, Woollard JR, He Q, Textor SC, Lerman A, Lerman LO. Mitochondrial protection restores renal function in swine atherosclerotic renovascular disease. Cardiovasc Res 2014; 103:461-72. [PMID: 24947415 DOI: 10.1093/cvr/cvu157] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
AIMS The mechanisms responsible for renal injury in atherosclerotic renovascular disease (ARVD) are incompletely understood, and few therapeutic options are available to reverse it. We hypothesized that chronic renal damage involves mitochondrial injury, and that mitochondrial protection would reduce renal fibrosis and dysfunction in ARVD pigs. METHODS AND RESULTS Domestic pigs were studied after 10 weeks of ARVD or sham, treated for the last 4 weeks with daily subcutaneous injections (5 days/week) of vehicle or Bendavia (0.1 mg/kg), a tetrapeptide that preserves cardiolipin content in the mitochondrial inner membrane. Single-kidney haemodynamics and function were studied using fast-computer tomography, oxygenation using blood oxygen level-dependent magnetic resonance imaging, microvascular architecture, oxidative stress, and fibrosis ex vivo. Cardiolipin content was assessed using mass spectrometry and staining. Renal endothelial function was studied in vivo and ex vivo. In addition, swine renal artery endothelial cells incubated with tert-butyl hydroperoxide were also treated with Bendavia. Stenotic-kidney renal blood flow (RBF) and glomerular filtration rate (GFR) decreased in ARVD + Vehicle compared with normal (318.8 ± 61.0 vs. 553.8 ± 82.8 mL/min and 48.0 ± 4.0 vs. 84.0 ± 3.8 mL/min, respectively) associated with loss of cardiolipin, intra-renal microvascular rarefaction, and hypoxia. Bendavia restored cardiolipin content in ARVD and improved vascular density, oxygenation, RBF (535.1 ± 24.9 mL/min), and GFR (86.6 ± 11.2 mL/min). Oxidative stress and fibrosis were ameliorated, and renovascular endothelial function normalized both in vivo and in vitro. CONCLUSION Preservation of mitochondrial cardiolipin attenuated swine stenotic-kidney microvascular loss and injury, and improved renal oxygenation, haemodynamics, and function. These observations implicate mitochondrial damage in renal deterioration in chronic experimental ARVD, and position the mitochondria as a central therapeutic target.
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Affiliation(s)
- Alfonso Eirin
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Behzad Ebrahimi
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Xin Zhang
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Xiang-Yang Zhu
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - John R Woollard
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Quan He
- Diabetes and Obesity Research Center, Sanford-Burnham Medical Research Institute, Orlando, FL, USA
| | - Stephen C Textor
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Amir Lerman
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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554
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Plouin PF, Amar L, Azizi M. [Angioplasty for atherosclerotic renal artery stenosis: the end of the story?]. Rev Med Interne 2014; 35:697-9. [PMID: 24909441 DOI: 10.1016/j.revmed.2014.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 05/07/2014] [Indexed: 10/25/2022]
Affiliation(s)
- P-F Plouin
- Unité d'hypertension artérielle et centre d'investigations cliniques, université Paris-Descartes, Sorbonne-Paris-Cité, hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, 20, rue Leblanc, 75908 Paris cedex 15, France.
| | - L Amar
- Unité d'hypertension artérielle et centre d'investigations cliniques, université Paris-Descartes, Sorbonne-Paris-Cité, hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, 20, rue Leblanc, 75908 Paris cedex 15, France
| | - M Azizi
- Unité d'hypertension artérielle et centre d'investigations cliniques, université Paris-Descartes, Sorbonne-Paris-Cité, hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, 20, rue Leblanc, 75908 Paris cedex 15, France
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555
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Cohen JB, Townsend RR. Use of renin-angiotensin system blockade in patients with renal artery stenosis. Clin J Am Soc Nephrol 2014; 9:1149-52. [PMID: 24903389 DOI: 10.2215/cjn.04240414] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Jordana B Cohen
- Renal, Electrolyte, and Hypertension Division, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Raymond R Townsend
- Renal, Electrolyte, and Hypertension Division, University of Pennsylvania, Philadelphia, Pennsylvania
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556
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Chrysant GS, Bates MC, Sullivan TM, Bachinsky WB, Popma JJ, Peng L, Omran HL, Jaff MR. Proper Patient Selection Yields Significant and Sustained Reduction in Systolic Blood Pressure Following Renal Artery Stenting in Patients With Uncontrolled Hypertension: Long-Term Results From the HERCULES Trial. J Clin Hypertens (Greenwich) 2014; 16:497-503. [PMID: 24909590 DOI: 10.1111/jch.12341] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 03/25/2014] [Accepted: 04/02/2014] [Indexed: 11/28/2022]
Affiliation(s)
| | - Mark C. Bates
- West Virginia University School of Medicine; Charleston WV
| | | | | | | | | | | | - Michael R. Jaff
- VasCore; The Vascular Ultrasound Core Laboratory; Massachusetts General Hospital; Boston MA
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557
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Evans KL, Tuttle KR, Folt DA, Dawson T, Haller ST, Brewster PS, He W, Jamerson K, Dworkin LD, Cutlip DE, Murphy TP, D'Agostino RB, Henrich W, Cooper CJ. Use of renin-angiotensin inhibitors in people with renal artery stenosis. Clin J Am Soc Nephrol 2014; 9:1199-206. [PMID: 24903387 DOI: 10.2215/cjn.11611113] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES People with atherosclerotic renal artery stenosis may benefit from renin-angiotensin inhibitors, angiotensin-converting enzyme inhibitors, and angiotensin-receptor blockers, but little is known about the factors associated with their use. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Cardiovascular Outcomes in Renal Atherosclerotic Lesions study (ClinicalTrials.gov identified: NCT00081731) is a prospective, international, multicenter clinical trial that randomly assigned participants with atherosclerotic renal artery stenosis who received optimal medical therapy to stenting versus no stenting from May 2005 through January 2010. At baseline, medication information was available from 853 of 931 randomly assigned participants. Kidney function was measured by serum creatinine-based eGFR at a core laboratory. RESULTS Before randomization, renin-angiotensin inhibitors were used in 419 (49%) of the 853 participants. Renin-angiotensin inhibitor use was lower in those with CKD (eGFR<60 ml/min per 1.73 m(2)) (58% versus 68%; P=0.004) and higher in individuals with diabetes (41% versus 27%; P<0.001). Presence of bilateral renal artery stenosis or congestive heart failure was not associated with renin-angiotensin inhibitor use. Although therapy with renin-angiotensin inhibitors varied by study site, differences in rates of use were not related to the characteristics of the site participants. Participants receiving a renin-angiotensin inhibitor had lower systolic BP (mean ± SD, 148 ± 23 versus 152 ± 23 mmHg; P=0.003) and more often had BP at goal (30% versus 22%; P=0.01). CONCLUSIONS Kidney function and diabetes were associated with renin-angiotensin inhibitor use. However, these or other clinical characteristics did not explain variability among study sites. Patients with renal artery stenosis who received renin-angiotensin inhibitor treatment had lower BP and were more likely to be at treatment goal.
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Affiliation(s)
- Kaleigh L Evans
- Department of Medicine, University of Toledo College of Medicine, Toledo, Ohio;
| | - Katherine R Tuttle
- Division of Nephrology, University of Washington School of Medicine, Providence Sacred Heart Medical Center, Spokane, Washington
| | - David A Folt
- Department of Medicine, University of Toledo College of Medicine, Toledo, Ohio
| | - Taylor Dawson
- Department of Medicine, University of Toledo College of Medicine, Toledo, Ohio
| | - Steven T Haller
- Department of Medicine, University of Toledo College of Medicine, Toledo, Ohio
| | - Pamela S Brewster
- Department of Medicine, University of Toledo College of Medicine, Toledo, Ohio
| | - Wencan He
- Department of Medicine, University of Toledo College of Medicine, Toledo, Ohio
| | - Kenneth Jamerson
- Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - Donald E Cutlip
- Harvard Clinical Research Institute, Boston, Massachusetts; and
| | - Timothy P Murphy
- Department of Diagnostic Imaging, Rhode Island Hospital and Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - William Henrich
- University of Texas Health Science Center, San Antonio, Texas
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558
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Afsar B, Covic A, Kanbay M. Renal artery stenting in patients with uncontrolled hypertension: should we? And to whom? J Clin Hypertens (Greenwich) 2014; 16:479-81. [PMID: 24889760 DOI: 10.1111/jch.12344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Baris Afsar
- Division of Nephrology, Department of Medicine, Konya Numune State Hospital, Konya, Turkey
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559
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Abstract
Renal artery stenosis (RAS) is a frequently encountered problem in clinical practice. The disease encompasses a broad spectrum of pathophysiologies and is associated with three major clinical syndromes: ischemic nephropathy, hypertension, and destabilizing cardiac syndromes. The two most common etiologies are fibromuscular dysplasia and atherosclerotic renal artery disease with atherosclerotic disease accounting for the vast majority of cases. Atherosclerotic renovascular disease has considerable overlap with atherosclerotic disease elsewhere and is associated with a poor prognosis. A wide range of diagnostic modalities and treatment approaches for RAS are available to clinicians, and with the advent of endovascular interventions, selecting the best course for a given patient has only grown more challenging. Several clinical trials have demonstrated some benefit with revascularization but not to the extent that many had hoped for or expected. Furthermore, much of the existing data is only marginally useful given significant flaws in study design and inherent bias. There remains a need for further identification of subgroups and appropriate indications in hopes of maximizing outcomes and avoiding unnecessary procedures in patients who would not benefit from treatment. In recent decades, the study of RAS has expanded and evolved rapidly. In this review, we will attempt to summarize the amassed body of literature with a focus on the epidemiology of RAS including prevalence, overlap with other atherosclerotic disease, and prognosis. We will also outline existing diagnostic and treatment approaches available to clinicians as well as summarize the findings of several major clinical trials. Finally, we will offer our perspective on future directions in the field.
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560
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Greco BA, Freda BJ. What is the optimal treatment for patients with atherosclerotic renal artery stenosis? Am J Kidney Dis 2014; 64:174-7. [PMID: 24815771 DOI: 10.1053/j.ajkd.2014.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 04/09/2014] [Indexed: 01/24/2023]
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561
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562
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563
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Khan AR, Sheikh MA, Kaw D, Cooper CJ, Khouri SJ. Rebuttal: Relationship of left ventricular hypertrophy, age, and renal artery stenosis. JOURNAL OF THE AMERICAN SOCIETY OF HYPERTENSION : JASH 2014; 8:361. [PMID: 24726948 DOI: 10.1016/j.jash.2014.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 02/19/2014] [Indexed: 06/03/2023]
Affiliation(s)
- Abdur Rahman Khan
- Divisions of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Mujeeb A Sheikh
- Divisions of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Dinkar Kaw
- Divisions of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Christopher J Cooper
- Divisions of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Samer J Khouri
- Divisions of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, University of Toledo Medical Center, Toledo, OH, USA
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564
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Banach M, Serban C, Aronow WS, Rysz J, Dragan S, Lerma EV, Apetrii M, Covic A. Lipid, blood pressure and kidney update 2013. Int Urol Nephrol 2014; 46:947-61. [PMID: 24573394 PMCID: PMC4012155 DOI: 10.1007/s11255-014-0657-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 01/28/2014] [Indexed: 12/24/2022]
Abstract
The year 2013 proved to be very exciting as far as landmark trials and new guidelines in the field of lipid disorders, blood pressure and kidney diseases. Among these are the International Atherosclerosis Society Global Recommendations for the Management of Dyslipidemia, European Society of Cardiology (ESC)/European Society of Hypertension Guidelines for the Management of Arterial Hypertension, American Diabetes Association Clinical Practice Recommendations, the Kidney Disease: Improving Global Outcomes Clinical Practice Guidelines for Managing Dyslipidemias in Chronic Kidney Disease (CKD) Patients, the American College of Cardiology/American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, the Joint National Committee Expert Panel (JNC 8) Evidence-Based Guideline for the Management of High Blood Pressure in Adults, the American Society of Hypertension/International Society of Hypertension Clinical Practice Guidelines for the Management of Hypertension in the Community, the American College of Physicians Clinical Practice Guideline on Screening, Monitoring, and Treatment of Stage 1-3 CKD and many important trials presented among others during the ESC Annual Congress in Amsterdam and the American Society of Nephrology Annual Meeting--Kidney Week in Atlanta, GA. The paper is an attempt to summarize the most important events and reports in the mentioned areas in the passing year.
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Affiliation(s)
- Maciej Banach
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Zeromskiego 113, 90-549, Lodz, Poland,
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565
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566
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Marshall RH, Schiffman MH, Winokur RS, Talenfeld AD, Siegel DN. Interventional Radiologic Techniques for Screening, Diagnosis and Treatment of Patients with Renal Artery Stenosis. Curr Urol Rep 2014; 15:414. [DOI: 10.1007/s11934-014-0414-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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567
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Granata A, Zanoli L, Clementi S, Fatuzzo P, Di Nicolò P, Fiorini F. Resistive intrarenal index: myth or reality? Br J Radiol 2014; 87:20140004. [PMID: 24734937 DOI: 10.1259/bjr.20140004] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
In renal diagnosis, the B-mode ultrasound is used to provide an accurate study of the renal morphology, whereas the colour and power Doppler are of strategic importance in providing qualitative and quantitative information about the renal vasculature, which can also be obtained through the assessment of the resistive index (RI). To date, this is one of the most sensitive parameters in the study of kidney diseases and allows us to quantify the changes in renal plasma flow. If a proper Doppler ultrasound examination is carried out and a critical analysis of the values obtained is performed, the RI measurement at the interlobar artery level has been suggested in the differential diagnosis between nephropathies. The aim of this review is to highlight the pathological conditions in which the study of intrarenal RI provides useful information about the pathophysiology of renal diseases in both the native and the transplanted kidneys.
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Affiliation(s)
- A Granata
- 1 Nephrology and Dialysis Unit, "St Giovanni di Dio" Hospital, Agrigento, Italy
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568
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Herrmann SMS, Saad A, Textor SC. Management of atherosclerotic renovascular disease after Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL). Nephrol Dial Transplant 2014; 30:366-75. [PMID: 24723543 DOI: 10.1093/ndt/gfu067] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Many patients with occlusive atherosclerotic renovascular disease (ARVD) may be managed effectively with medical therapy for several years without endovascular stenting, as demonstrated by randomized, prospective trials including the Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial, the Angioplasty and Stenting for Renal Artery Lesions (ASTRAL) trial and the Stent Placement and Blood Pressure and Lipid-Lowering for the Prevention of Progression of Renal Dysfunction Caused by Atherosclerotic Ostial Stenosis of the Renal Artery (STAR) and ASTRAL. These trials share the limitation of excluding subsets of patients with high-risk clinical presentations, including episodic pulmonary edema and rapidly progressing renal failure and hypertension. Although hemodynamically significant, ARVD can reduce renal blood flow and glomerular filtration rate; adaptive mechanisms preserve both cortical and medullary oxygenation over a wide range of vascular occlusion. Progression of ARVD to severe vascular compromise eventually produces cortical hypoxia, however, associated with active inflammatory cytokine release and cellular infiltration of the renal parenchyma. In such cases ARVD produces a loss of glomerular filtration rate that no longer is reversible simply by restoring vessel patency with technically successful renal revascularization. Each of these trials reported adverse renal functional outcomes ranging between 16 and 22% over periods of 2-5 years of follow-up. Blood pressure control and medication adjustment may become more difficult with declining renal function and may prevent the use of angiotensin receptor blocker and angiotensin-converting enzyme inhibitors. The objective of this review is to evaluate the current management of ARVD for clinical nephrologists in the context of recent randomized clinical trials and experimental research.
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Affiliation(s)
| | - Ahmed Saad
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Stephen C Textor
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
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569
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570
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Weber BR, Dieter RS. Renal artery stenosis: 'an answer looking for a question'? Interv Cardiol 2014. [DOI: 10.2217/ica.14.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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571
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Colyer WR, Cooper CJ. The future of renal artery stenting. Interv Cardiol 2014. [DOI: 10.2217/ica.14.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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572
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Alderson HV, Ritchie JP, Kalra PA. Revascularization as a treatment to improve renal function. Int J Nephrol Renovasc Dis 2014; 7:89-99. [PMID: 24600242 PMCID: PMC3933706 DOI: 10.2147/ijnrd.s35633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
An aging atherosclerosis-prone population has led to an increase in the prevalence of atherosclerotic renovascular disease (ARVD). Medical management of this disease, as with other atherosclerotic conditions, has improved over the past decade. Despite the widespread availability of endovascular revascularization procedures, there is inconsistent evidence of benefit in ARVD and no clear consensus of opinion as to the best way to select suitable patients for revascularization. Several published randomized controlled trials have attempted to provide clearer evidence for best practice in ARVD, but they have done so with varying clarity and success. In this review, we provide an overview of ARVD and its effect on renal function. We present the currently available evidence for best practice in the management of patients with ARVD with a particular focus on revascularization as a treatment to improve renal function. We provide a brief overview of the evidence for revascularization in other causes of renal artery stenosis.
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Affiliation(s)
- Helen V Alderson
- The University of Manchester, Manchester Academic Health Sciences Centre, Vascular Research Group, Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - James P Ritchie
- The University of Manchester, Manchester Academic Health Sciences Centre, Vascular Research Group, Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - Philip A Kalra
- The University of Manchester, Manchester Academic Health Sciences Centre, Vascular Research Group, Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, UK
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573
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Bates MC. Navigating the renal stent empirical maze. Catheter Cardiovasc Interv 2014; 83:610-1. [PMID: 24532329 DOI: 10.1002/ccd.25401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 01/12/2014] [Indexed: 11/07/2022]
Affiliation(s)
- Mark C Bates
- Department of Surgery, West Virginia University School of Medicine, Charleston, West Virginia 25304
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574
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Estudos ASTRAL e CORAL: fim da revascularização endoluminal na estenose ateroesclerótica da artéria renal ou um novo princípio? ANGIOLOGIA E CIRURGIA VASCULAR 2014. [DOI: 10.1016/s1646-706x(14)70024-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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575
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Predictive role of renal resistive index for clinical outcome after revascularization in hypertensive patients with atherosclerotic renal artery stenosis: a monocentric observational study. Cardiovasc Ultrasound 2014; 12:9. [PMID: 24555729 PMCID: PMC3937242 DOI: 10.1186/1476-7120-12-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 02/13/2014] [Indexed: 11/10/2022] Open
Abstract
Background The present study evaluated the predictive value of renal resistive index (RI) for renal function and blood pressure (BP) outcome in hypertensive patients with unilateral atherosclerotic renal artery stenosis submitted to successful revascularization. Methods In 158 hypertensive patients with atherosclerotic renal artery stenosis RI was acquired. Twelve months after revascularization, they were classified on the basis of renal function and BP outcome as benefit (BP < 140/90 mmHg or diastolic BP reduction > 15 mmHg with the same of reduced drugs; decrease in glomerular filtration rate > 20%), or failure. Results Regarding renal function outcome, RI in the stenotic and in the contralateral kidney were significantly higher in patients with failure (n = 20) than in those with benefit (0.72 ± 0.11 vs 0.61 ± 0.11 and 0.76 ± 0.08 vs 0.66 ± 0.09, p < 0.05). Among different cutpoints generated, RI in the contralateral kidney >0.73 provided the largest area under the curve (0.77), and the highest sensitivity (80%) and specificity (72%). In the multivariate logistic regression analysis, RI in the contralateral kidney >0.73 was an independent predictor of a failure in renal function outcome. Regarding BP outcome, patients with no benefit from revascularization (n = 60) had similar RI in the stenotic and contralateral kidney (p = ns), but presented higher pulse pressure, albuminuria and hypertension duration in comparison to patients with improved BP control. Conclusions RI in the contralateral kidney is an independent predictor of renal function outcome after successful revascularization in hypertensive patients with unilateral atherosclerotic renal artery stenosis, whereas it is not able to predict blood pressure outcome.
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576
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Mann SJ, Sos TA. The cardiovascular outcomes in renal atherosclerotic lesions study and the future of renal artery stenting. J Clin Hypertens (Greenwich) 2014; 16:162-5. [PMID: 24708379 DOI: 10.1111/jch.12270] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Samuel J Mann
- New York Presbyterian Hospital-Weill Cornell Medical Center, Hypertension Center, New York, NY
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577
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578
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Carotid Endarterectomy Versus Carotid Artery Stenting. JACC Cardiovasc Interv 2014; 7:169-170. [DOI: 10.1016/j.jcin.2013.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 12/07/2013] [Indexed: 11/23/2022]
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579
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Affiliation(s)
- John A Bittl
- From the Munroe Regional Medical Center, Ocala, FL
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580
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Ishimori N, Kinugawa S, Yamada S, Yokoshiki H, Mitsuyama H, Tsutsui H. Report of the American Heart Association (AHA) Scientific Sessions 2013, Dallas. Circ J 2013; 78:51-6. [PMID: 24334639 DOI: 10.1253/circj.cj-13-1466] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The American Heart Association (AHA) Scientific Sessions were held in Dallas on November 16-20, 2013. The meeting is one of the most leading conferences of cardiology in the world, with over 18,000 professional attendees from more than 105 countries. There were 315 invited sessions and 443 abstract sessions, comprising more than 5,000 presentations. The sessions were expanded to 26 program tracks, which included and integrated basic, translational, clinical, and population science. In the series of late-breaking sessions, updates of results from 20 clinical trials were disclosed. Japanese scientists submitted the second most abstracts to the Scientific Sessions in 2013. We appreciate the significant contribution to the sessions by Japanese cardiologists as well as the Japanese Circulation Society.
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Affiliation(s)
- Naoki Ishimori
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
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