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Modrall JG, Jeon-Slaughter H, Ramanan B, Tsai S, Miller RT, Hastings JL. Predicting renal function response to renal artery stenting. J Vasc Surg 2023; 78:102-110.e1. [PMID: 36868330 DOI: 10.1016/j.jvs.2023.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/13/2023] [Accepted: 02/15/2023] [Indexed: 03/05/2023]
Abstract
OBJECTIVE The Cardiovascular Outcomes in Renal Atherosclerotic Lesions Trial found no benefit of renal artery stenting (RAS) over medical therapy, although it was underpowered to detect a benefit among patients with chronic kidney disease (CKD). A post hoc analysis demonstrated improved event-free survival after RAS for patients whose renal function improved by 20% or more. A significant obstacle to achieving this benefit is the inability to predict which patients' renal function will improve from RAS. The objectives of the current study were to identify predictors of renal function response to RAS. METHODS The Veteran Affairs Corporate Data Warehouse was queried for patients who underwent RAS between 2000 and 2021. The primary outcome was improvement in renal function (estimated glomerular filtration rate [eGFR]) after stenting. Patients were categorized as responders if the eGFR at 30 days or greater after stenting increased by 20% or more compared with before stenting. All others were nonresponders. RESULTS The study cohort included 695 patients with a median follow-up of 7.1 years (interquartile range, 3.7-11.6 years). Based on postoperative change in eGFR, 202 stented patients (29.1%) were responders, and the remainder (n = 493 [70.9%]) were nonresponders. Before RAS, responders had a significantly higher mean serum creatinine, lower mean eGFR, and higher rate of decline of preoperative GFR in the months before stenting. After stenting, responders had a 26.1% increase in eGFR, compared with before stenting (P < .0001), which remained stable during follow-up. In contrast, nonresponders had a progressive 5.5% decrease in eGFR after stenting. Logistic regression analysis identified three predictors of renal function response to stenting: (1) diabetes (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.44-0.91; P = .013), (2) CKD stages 3b or 4 (OR, 1.80; 95% CI, 1.26-2.57; P = .001), and (3) rate of decline in preoperative eGFR per week before stenting (OR, 1.21; 95% CI, 1.05-1.39; P = .008). CKD stages 3b and 4 and the rate of decline in preoperative eGFR are positive predictors of renal function response to stenting, whereas diabetes is a negative predictor. CONCLUSIONS Based on our data, patients in CKD stages 3b and 4 (eGFR 15-44 mL/min/1.73 m2) are the only subgroups with a significant probability of improved renal function after RAS. The rate of decline of preoperative eGFR over the months before stenting is a powerful discriminator of patients who are most likely to benefit from RAS. Specifically, patients with a more rapid decrease in eGFR before stenting have a significantly greater probability of improved renal function with RAS. In contrast, diabetes is a negative predictor of improved renal function, so interventionalists should be circumspect about RAS in diabetic patients.
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Affiliation(s)
- J Gregory Modrall
- Surgical Service, Dallas Veterans Affairs Medical Center, Dallas, TX; Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
| | | | - Bala Ramanan
- Surgical Service, Dallas Veterans Affairs Medical Center, Dallas, TX; Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Shirling Tsai
- Surgical Service, Dallas Veterans Affairs Medical Center, Dallas, TX; Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - R Tyler Miller
- Medicine Service, Dallas Veterans Affairs Medical Center, Dallas, TX; Division of Nephrology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jeffrey L Hastings
- Medicine Service, Dallas Veterans Affairs Medical Center, Dallas, TX; Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
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Modrall JG, Zhu H, Prasad T, Moe O, Dworkin LD, Cutlip DE, Murphy TP, Cooper CJ, Toto R. Retrieval of Renal Function After Renal Artery Stenting Improves Event-Free Survival in a Sub-group Analysis of the Cardiovascular Outcomes in Renal Atherosclerotic Lesions Trial. J Vasc Surg 2023; 77:1685-1692.e2. [PMID: 36736864 DOI: 10.1016/j.jvs.2022.12.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) Trial, a multicenter randomized controlled trial with 947 patients, concluded that there was no benefit of renal artery stenting (RAS) over medical therapy. However, patients with chronic kidney disease (CKD) were not analyzed separately in the CORAL trial. CKD is a risk factor for cardiovascular and renal morbidity. We hypothesized that improved renal function after RAS would be associated with increased long-term survival and a lower risk of cardiovascular and renal events in patients with CKD. METHODS This post hoc analysis of the CORAL Trial included 842 patients with CKD stages 2-4 at baseline who were randomized to optimal medical therapy alone (OMT; n= 432) or RAS plus OMT (RAS+OMT; n = 410). Patients were categorized as "responders" or "non-responders" based on change in estimated glomerular filtration rate (eGFR) from baseline to last follow-up (median 3.6 years, interquartile range 2.6-4.6 years). Responders were defined by a 20% or greater increase in eGFR from baseline; all others were non-responders. Event-free survival was defined as freedom from death and multiple cardiovascular and renal complications. Event-free survival was analyzed using the Kaplan-Meier method and log-rank test. Multivariable Cox proportional hazards regression analysis was used to identify independent predictors of event-free survival. RESULTS The RAS+OMT group had a higher proportion of patients with improved renal function (≥20% increase in eGFR over baseline), compared to the OMT group (25.6% vs. 17.1%; P = .003). However, event-free survival was no different for the two cohorts (P = .18 by log-rank test). Multivariable Cox proportional hazards regression analysis identified four variables that independently correlated with event-free survival for the stented cohort. Higher preoperative eGFR (Hazard Ratio [HR] = 0.98, 95% Confidence Interval [CI] 0.96-0.99; P = .002) and being a responder to stenting (HR = 0.49, 95% CI 0.26-0.95; P = .033) increased event-free survival, while history of congestive heart failure (HR 2.52, 95% CI 1.46-4.35; P < .001) and higher preoperative systolic BP (HR 1.02, 95% CI 1.01-1.03; P = .002) decreased event-free survival. Within the stented group, 105 of 410 patients (25.6%) were responders. Event-free survival was superior for responders, compared to non-responders (P=0.009 by log-rank test). The only independent preoperative negative predictor of improved renal function after stenting was diabetes (Odds Ratio 0.37, 95% CI 0.16-0.84; P = 0.017), which decreased the probability of improved renal function after RAS+OMT. A subset of patients (23.4%) after RAS had worsened renal function, but OMT alone produced an equivalent incidence of worsened renal function. Increased urine albumin/creatinine ratio was an independent predictor of worsened renal function after RAS. CONCLUSIONS CORAL participants who demonstrated improved kidney function after RAS+OMT demonstrated improved event-free survival. This finding reinforces the need for predictors of outcome to guide patient selection for RAS.
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Affiliation(s)
- J Gregory Modrall
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center.
| | - Hong Zhu
- Department of Public Health Sciences, University of Virginia School of Medicine
| | - Tanushree Prasad
- School of Public Health, University of Texas Southwestern Medical Center
| | - Orson Moe
- Division of Nephrology, Department of Internal Medicine; Department of Physiology; Charles and Jane Pak Center for Mineral Metabolism, University of Texas Southwestern Medical Center
| | | | | | | | | | - Robert Toto
- Division of Nephrology, Department of Internal Medicine; Charles and Jane Pak Center for Mineral Metabolism, University of Texas Southwestern Medical Center
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Kawano M, Suzuki K, Fujimura N, Endo A, Kato A, Fujii K, Komatsu M, Takahashi T, Ryuzaki M, Harada H. Ultra-Low-Dose Contrast Using Transluminal Renal Angioplasty: The ULTRA Study. Vasc Endovascular Surg 2022; 57:324-330. [PMID: 36509460 DOI: 10.1177/15385744221145867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although severe atherosclerotic renal artery stenosis (ARAS) is a predictor of future cardiovascular events, large trials have not shown the benefits of percutaneous transluminal renal angioplasty (PTRA). This study aimed to validate the safety and efficacy of PTRA using low-concentration digital subtraction angiography (LC-DSA) in patients with severe ARAS and advanced chronic kidney disease (CKD). MATERIALS AND METHODS This prospective study was conducted between August 2018 and October 2021. Eighteen patients with 20 lesions, CKD stage 3b or worse, and significant renal artery stenosis were included and underwent PTRA using ultra-low-dose contrast medium. The primary endpoint was a change in renal function based on serum creatinine (sCr) level. RESULTS The mean sCr level significantly improved from 3.34 ± 1.8 mg/dL pre-PTRA to 2.48 ± 1.19 mg/dL at 1 month post-PTRA (P = .02). The mean amount of contrast used was 8.3 ± 3.9 mL per vessel. More severe stenosis and rapid deterioration of renal function before treatment were associated with improved kidney function. No cardiovascular or renal complications such as stroke or contrast-induced nephropathy were observed during the 30-day period. CONCLUSIONS PTRA using an ultra-low-dose contrast medium is safe and provides acceptable results.
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Affiliation(s)
- Megumi Kawano
- Department of Cardiology, 38562Tokyo Saiseikai Central Hospital, Minato-ku, Japan
| | - Kenji Suzuki
- Department of Cardiology, 38562Tokyo Saiseikai Central Hospital, Minato-ku, Japan
| | - Naoki Fujimura
- Department of Vascular Surgery, 38562Tokyo Saiseikai Central Hospital, Minato-ku, Japan
| | - Ayaka Endo
- Department of Cardiology, 38562Tokyo Saiseikai Central Hospital, Minato-ku, Japan
| | - Ai Kato
- Department of Nephrology, 38562Tokyo Saiseikai Central Hospital, Minato-ku, Japan
| | - Kentaro Fujii
- Department of Nephrology, 38562Tokyo Saiseikai Central Hospital, Minato-ku, Japan
| | - Motoaki Komatsu
- Department of Nephrology, 38562Tokyo Saiseikai Central Hospital, Minato-ku, Japan
| | - Toshiyuki Takahashi
- Department of Cardiology, 38562Tokyo Saiseikai Central Hospital, Minato-ku, Japan
| | - Munekazu Ryuzaki
- Department of Nephrology, 38562Tokyo Saiseikai Central Hospital, Minato-ku, Japan
| | - Hirohisa Harada
- Department of Vascular Surgery, 38562Tokyo Saiseikai Central Hospital, Minato-ku, Japan
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Takahashi EA, Harmsen WS, Misra S. Impact of Renal Function Trajectory on Renal Replacement Therapy and Mortality Risk after Renal Artery Revascularization. J Vasc Interv Radiol 2019; 31:592-597. [PMID: 31530493 DOI: 10.1016/j.jvir.2019.07.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 07/20/2019] [Accepted: 07/22/2019] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To determine the impact of renal function trajectory, defined as the change in renal function over time before and after renal artery stent placement, on long-term risk for renal replacement therapy (RRT) and mortality. MATERIALS AND METHODS Estimated glomerular filtration rates (eGFRs) 6-12 months before renal artery stent placement, at the time of intervention, and 6-12 months after intervention were determined in 398 patients. The effect of eGFR change before and after renal artery stent placement was calculated. Cox proportional-hazards ratio was used to determine the risks for RRT and all-cause mortality. RESULTS The risk for RRT was significantly influenced by eGFR change from the time of intervention to follow-up at 6-12 month after treatment (P = .02). In addition, among patients with a postintervention eGFR ≤ 40 mL/min/1.73 m2, for every 1 unit of eGFR increase, there was a significant decrease in RRT and all-cause mortality (P < .001 and P < .001, respectively). Secondary parameters that increased RRT risk included diabetes at the time of intervention (P = .03), increased baseline proteinuria (P < .001), and stage 4 or 5 chronic kidney disease (CKD; P = .01 and P = .003, respectively). Multivariate analysis demonstrated higher all-cause mortality rates among patients with diabetes at the time of intervention (P = .009). CONCLUSIONS Postintervention eGFR trajectory improvement approaching 40 mL/min/1.73 m2 was associated with decreased RRT and mortality risk. These findings suggest that patients with advanced CKD and renal artery stenosis may benefit from revascularization regardless of their preinterventional renal function measurement.
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Affiliation(s)
- Edwin A Takahashi
- Department of Radiology, Mayo Clinic, Rochester, 200 First St. SW, Rochester, MN 55905; Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, 200 First St. SW, Rochester, MN 55905
| | - William S Harmsen
- Department of Radiology, Mayo Clinic, Rochester, 200 First St. SW, Rochester, MN 55905; Department of Clinical Statistics, Mayo Clinic, Rochester, 200 First St. SW, Rochester, MN 55905
| | - Sanjay Misra
- Department of Radiology, Mayo Clinic, Rochester, 200 First St. SW, Rochester, MN 55905; Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, 200 First St. SW, Rochester, MN 55905.
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Cooper EL, Xie Y, Nguyen H, Brewster PS, Sholl H, Sharrett M, Ren K, Chen T, Tuttle KR, Haller ST, Jamerson K, Murphy TP, D'Agostino RB, Massaro JM, Henrich W, Cooper CJ, Cutlip DE, Dworkin LD, Shapiro JI. Early Rapid Decline in Kidney Function in Medically Managed Patients With Atherosclerotic Renal Artery Stenosis. J Am Heart Assoc 2019; 8:e012366. [PMID: 31433717 PMCID: PMC6585374 DOI: 10.1161/jaha.119.012366] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 04/26/2019] [Indexed: 11/29/2022]
Abstract
Background Early rapid declines of kidney function may occur in patients with atherosclerotic renal artery stenosis with institution of medical therapy. The causes and consequences are not well understood. Methods and Results Patients enrolled in the medical therapy-only arm of the CORAL (Cardiovascular Outcomes With Renal Artery Lesions) study were assessed for a rapid decline (RD) in estimated glomerular filtration rate (eGFR), defined as a ≥30% decrease from baseline to either 3 months, 6 months, or both. In the medical therapy-only cohort, eGFR was available in 359 subjects at all time points, the subjects were followed for a median of 4.72 years, and 66 of 359 (18%) subjects experienced an early RD. Baseline log cystatin C (odds ratio, 1.78 [1.11-2.85]; P=0.02), age (odds ratio, 1.04 [1.00-1.07]; P<0.05), and Chronic Kidney Disease Epidemiology Collaboration creatinine eGFR (odds ratio, 1.86 [1.15-3.0]; P=0.01) were associated with an early RD. Despite continued medical therapy only, the RD group had an improvement in eGFR at 1 year (6.9%; P=0.04). The RD and nondecline groups were not significantly different for clinical events and all-cause mortality (P=0.78 and P=0.76, respectively). Similarly, renal replacement therapy occurred in 1 of 66 (1.5%) of the RD patients and in 6 of 294 (2%) of the nondecline patients. The regression to the mean of improvement in eGFR at 1 year in the RD group was estimated at 5.8±7.1%. Conclusions Early rapid declines in kidney function may occur in patients with renal artery stenosis when medical therapy is initiated, and their clinical outcomes are comparable to those without such a decline, when medical therapy only is continued.
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Affiliation(s)
- Emily L. Cooper
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Yanmei Xie
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Hanh Nguyen
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Pamela S. Brewster
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Haden Sholl
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Megan Sharrett
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Kaili Ren
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Tian Chen
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Katherine R. Tuttle
- Division of NephrologyUniversity of Washington School of MedicineProvidence Sacred Heart Medical CenterSpokaneWA
| | - Steven T. Haller
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | | | - Timothy P. Murphy
- Department of Diagnostic ImagingRhode Island Hospital and Alpert Medical School of Brown UniversityProvidenceRI
| | | | - Joseph M. Massaro
- Department of BiostatisticsSchool of Public HealthBoston UniversityBostonMA
| | | | - Christopher J. Cooper
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Donald E. Cutlip
- Department of MedicineHarvard UniversityBeth Israel Deaconess Medical CenterBostonMA
| | - Lance D. Dworkin
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
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Modrall JG, Trimmer C, Tsai S, Kirkwood ML, Ali M, Rectenwald JE, Timaran CH, Rosero EB. Renal Salvage with Renal Artery Stenting Improves Long-term Survival. Ann Vasc Surg 2017; 45:106-111. [DOI: 10.1016/j.avsg.2017.05.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 05/02/2017] [Accepted: 05/26/2017] [Indexed: 10/19/2022]
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Misra S, Khosla A, Allred J, Harmsen WS, Textor SC, McKusick MA. Mortality and Renal Replacement Therapy after Renal Artery Stent Placement for Atherosclerotic Renovascular Disease. J Vasc Interv Radiol 2016; 27:1215-24. [PMID: 27296703 DOI: 10.1016/j.jvir.2016.05.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 04/29/2016] [Accepted: 05/01/2016] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To identify risk factors for progression to renal replacement therapy (RRT) and all-cause mortality in patients who underwent renal artery (RA) stent placement for atherosclerotic renal artery stenosis (RAS). MATERIALS AND METHODS A retrospective study from June 1996 to June 2009 identified 1,052 patients who underwent RA stent placement. Glomerular filtration rate at time of RA stent placement was estimated from serum creatinine level and divided into chronic kidney disease (CKD) stages 1-5. Univariate and multivariable Cox proportional hazards models were used to determine which factors were associated with each endpoint. RESULTS Times to progression to all-cause mortality and RRT were similar for CKD stages 1/2/3A and served as the reference group. In multivariable analysis, high-grade proteinuria (P < .001) and higher CKD stage (5 vs 1/2/3A [P < .001], 4 vs 1/2/3A [P < .001], 3B vs 1/2/3A [P = .02]) remained independently associated with increased risk of progression to RRT. Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) use was associated with decreased risk of progression to RRT (P = .03). Higher CKD stage (5 vs 1/2/3A [P < .001], 4 vs 1/2/3A [P = .004]), carotid artery disease (P < .001), diabetes mellitus (P = .002), and high-grade proteinuria (P < .001) remained independently associated with all-cause mortality. Statin use was associated with decreased risk of all-cause mortality (P < .001). CONCLUSIONS Patients with atherosclerotic RAS who undergo RA stent placement and have high-grade proteinuria and CKD stage 3B/4/5 have increased risk of progression to RRT. Patients with high-grade proteinuria, CKD stage 3B/4/5, carotid artery disease, or diabetes have increased risk for all-cause mortality after renal artery stent placement. Patients receiving ACEI/ARBs have a decreased risk of progression to RRT, and patients receiving statins have a decreased risk of all-cause mortality.
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Affiliation(s)
- Sanjay Misra
- Vascular and Interventional Radiology Translational Laboratory, Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.
| | - Ankaj Khosla
- Vascular and Interventional Radiology Translational Laboratory, Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Jake Allred
- Vascular and Interventional Radiology Translational Laboratory, Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - William S Harmsen
- Vascular and Interventional Radiology Translational Laboratory, Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Stephen C Textor
- Division of Nephrology and Hypertension, Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Michael A McKusick
- Division of Vascular and Interventional Radiology, Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
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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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Nanjundappa A, Bates MC. Clinical strategy for treating renal artery stenosis and contemporary tactics for renal artery stenting. Interv Cardiol 2012. [DOI: 10.2217/ica.12.41] [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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Modrall JG, Timaran CH, Rosero EB, Chung J, Plummer M, Valentine RJ, Trimmer C. Longitudinal changes in kidney parenchymal volume associated with renal artery stenting. J Vasc Surg 2012; 55:774-80; discussion 780. [PMID: 22264697 DOI: 10.1016/j.jvs.2011.10.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2011] [Revised: 10/10/2011] [Accepted: 10/11/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study assessed the longitudinal changes in renal volume after renal artery stenting (RAS) to determine if renal mass is preserved by stenting. METHODS The study cohort consisted of 38 patients with longitudinal imaging available for renal volume quantification before and after RAS. Renal volume was estimated as (kidney length) × (width) × (depth/2) based on preoperative renal imaging. For each patient, the clinical response of blood pressure (BP) and renal function to RAS was categorized according to modified American Heart Association guidelines. Changes in renal volume were assessed using paired nonparametric analyses. RESULTS The cohort was a median age of 69 years (interquartile range [IQR], 60-74 years). A favorable BP response was observed in 11 of 38 patients (28.9%). At a median interval between imaging studies of 21 months (IQR, 13-32 months), ipsilateral renal volume was significantly increased from baseline (146.8 vs 133.8 cm(3);P = .02). This represents a 6.9% relative increase in ipsilateral kidney volume from baseline. A significant negative correlation between preoperative renal volume and the relative change in renal volume postoperatively (r = -0.42; P = .0055) suggests that smaller kidneys experienced the greatest gains in renal volume after stenting. It is noteworthy that the 25 patients with no change in BP or renal function-clinical failures using traditional definitions-experienced a 12% relative increase in ipsilateral renal volume after RAS. Multivariate analysis determined that stable or improved renal volume after stenting was an independent predictor of stable or improved long-term renal function (odds ratio, 0.008; 95% confidence interval, 0.000-0.206; P = .004). CONCLUSIONS These data lend credence to the belief that RAS preserves renal mass in some patients. This benefit of RAS even extends to those patients who would be considered treatment failures by traditional definitions. Patients with stable or increased renal volume after RAS had more stable renal function during long-term follow-up, whereas patients with renal volume loss after stenting were prone to deterioration of renal function.
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Modrall JG, Rosero EB, Timaran CH, Anthony T, Chung J, Valentine RJ, Trimmer C. Assessing outcomes to determine whether symptoms related to hypertension justify renal artery stenting. J Vasc Surg 2011; 55:413-9; discussion 419-20. [PMID: 22133456 DOI: 10.1016/j.jvs.2011.08.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2011] [Revised: 08/30/2011] [Accepted: 08/30/2011] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The goal of the study was to determine the blood pressure (BP) response to renal artery stenting (RAS) for patients with hypertension urgency, hypertension emergency, and angina with congestive heart failure (angina/congestive heart failure [CHF]). METHODS Patients who underwent RAS for hypertension emergencies (n = 13), hypertension urgencies (n = 25), and angina/CHF (n = 14) were included in the analysis. By convention, hypertension urgency was defined by a sustained systolic BP ≥ 180 mm Hg or diastolic BP ≥ 120 mm Hg, while the definition of hypertension emergency required the same BP parameters plus hypertension-related symptoms prompting hospitalization. Patient-specific response to RAS was defined according to modified American Heart Association reporting guidelines. RESULTS The study cohort of 52 patients had a median age of 66 years (interquartile range 58-72). The BP response to RAS varied significantly according to the indication for RAS. Hypertension emergency provided the highest BP response rate (85%), while the response rate was significantly lower for hypertension urgency (52%) and angina/CHF (7%; P = .03). Only 1 of 14 patients with angina/CHF was a BP responder. Multivariate analysis showed that hypertension urgency or emergency were not independent predictors of BP response to RAS. Instead, the only independent predictor of a favorable BP response was the number of preoperative antihypertensive medications (odds ratio 7.5; 95% confidence interval 2.5-22.9; P = .0004), which is another indicator of the severity of hypertension. Angina/CHF was an independent predictor of failure to respond to RAS (odds ratio 118.6; 95% confidence interval 2.8-999.9; P = .013). CONCLUSIONS Hypertension urgency and emergency are clinical manifestations of severe hypertension, but the number of preoperative antihypertensive medications proved to be a better predictor of a favorable BP response to RAS. In contrast, angina/CHF was a predictor of failure to respond to stenting, providing further evidence against the practice of incidental stenting during coronary interventions.
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Affiliation(s)
- J Gregory Modrall
- Dallas Veterans Affairs Medical Center, University of Texas Southwestern Medical School, Dallas, TX, USA.
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