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Vukadinović D, Lauder L, Kandzari DE, Bhatt DL, Kirtane A, Edelman ER, Schmieder RE, Azizi M, Böhm M, Mahfoud F. Effects of catheter-based renal denervation in hypertension: a systematic review and meta-analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.06.12.24308869. [PMID: 38946962 PMCID: PMC11213059 DOI: 10.1101/2024.06.12.24308869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Background Several sham-controlled trials have investigated the efficacy and safety of catheter-based renal denervation (RDN) with mixed outcomes. Aim To perform a comprehensive meta-analysis of all randomized, sham-controlled trials investigating RDN with first- and second-generation devices in hypertension. Methods We searched MEDLINE and Cochrane Library for eligible trials. Outcomes included both efficacy (24-hour and office systolic [SBP] and diastolic blood pressure [DBP]) and safety (all-cause death, vascular complication, renal artery stenosis >70%, hypertensive crisis) of RDN. We performed a study-level, pairwise, random-effects meta-analysis of the summary data. Results Ten trials comprising 2,478 patients with hypertension while being either off- or on-treatment were included. Compared with sham, RDN reduced 24-hour and office systolic BP by 4.4 mmHg (95%CI -6.1, -2.7, p<0.00001) and 6.6 mmHg (95%CI -9.7, -3.6, p<0.0001), respectively. The 24-hour and office diastolic BP paralleled these findings (-2.6 mmHg, 95%CI - 3.6, -1.5, p<0.00001; -3.5 mmHg, 95%CI -5.4, -1.6, p=0.0003). There was no difference in 24-hour and office SBP reduction between trials with and without concomitant antihypertensive medication (p for interaction 0.62 and 0.73, respectively). There was no relevant difference concerning vascular complications (OR 1.69, 95%CI 0.57-5.0, p=0.34), renal artery stenosis (OR 1.50, 95%CI 0.06-36.97, p=0.80), hypertensive crisis (OR 0.65, 95%CI 0.30-1.38, p=0.26) and all-cause death (OR 1.76, 95%CI 0.34-9.20, p=0.50) between RDN and sham groups. Change of renal function based on eGFR was comparable between groups (p for interaction 0.84). There was significant heterogeneity between trials. Conclusions RDN safely reduces ambulatory and office SBP/DBP vs. a sham procedure in the presence and absence of antihypertensive medication. Clinical Perspective What is new?Several sham-controlled trials have investigated the efficacy and safety of catheter-based renal denervation (RDN) with mixed outcomes.This comprehensive meta-analysis comprising 2,478 patients shows that irrespective of the utilized method (radiofrequency-, ultrasound-or alcohol-mediated), renal denervation effectively reduced ambulatory and office systolic blood pressure.Renal denervation exhibited no additional risk concerning vascular injury or renal function impairment.What are the clinical implications?This meta-analysis supports current guidelines/consensus statements that renal denervation represents an additive treatment option in carefully selected patients with uncontrolled hypertension.
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Lauder L, Kandzari DE, Lüscher TF, Mahfoud F. Renal denervation in the management of hypertension. EUROINTERVENTION 2024; 20:e467-e478. [PMID: 38629418 PMCID: PMC11017226 DOI: 10.4244/eij-d-23-00836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/09/2024] [Indexed: 04/19/2024]
Abstract
Arterial hypertension is a global leading cause of cardiovascular, cerebrovascular, and renal disease, as well as mortality. Although pharmacotherapy is safe and effective in lowering blood pressure (BP) and cardiovascular disease risk, BP control remains poor, and the mortality rates associated with high BP have been steadily increasing. Device-based therapies have been investigated to overcome barriers to pharmacotherapy, including non-adherence and low rates of persistence to daily medications. Among these device-based therapies, catheter-based renal denervation (RDN) has been most extensively examined over the past 15 years. In this state-of-the-art article, we summarise the rationale for RDN, review the available evidence, provide recommendations for a safe procedure, and discuss the role of RDN in current guidelines and clinical practice.
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Affiliation(s)
- Lucas Lauder
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes and Saarland University, Homburg, Germany
| | | | - Thomas F Lüscher
- Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
- Royal Brompton & Harefield Hospitals, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes and Saarland University, Homburg, Germany
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
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Azzam O, Nejad SH, Carnagarin R, Nolde JM, Galindo-Kiuchi M, Schlaich MP. Taming resistant hypertension: The promise of novel pharmacologic approaches and renal denervation. Br J Pharmacol 2024; 181:319-339. [PMID: 37715452 DOI: 10.1111/bph.16247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 08/11/2023] [Accepted: 09/02/2023] [Indexed: 09/17/2023] Open
Abstract
Resistant hypertension is associated with an exceedingly high cardiovascular risk and there remains an unmet therapeutic need driven by pathophysiologic pathways unaddressed by guideline-recommended therapy. While spironolactone is widely considered as the preferable fourth-line drug, its broad application is limited by its side effect profile, especially off-target steroid receptor-mediated effects and hyperkalaemia in at-risk subpopulations. Recent landmark trials have reported promising safety and efficacy results for a number of novel compounds targeting relevant pathophysiologic pathways that remain unopposed by contemporary drugs. These include the dual endothelin receptor antagonist, aprocitentan, the aldosterone synthase inhibitor, baxdrostat and the nonsteroidal mineralocorticoid receptor antagonist finerenone. Furthermore, the evidence base for consideration of catheter-based renal denervation as a safe and effective adjunct therapeutic approach across the clinical spectrum of hypertension has been further substantiated. This review will summarise the recently published evidence on novel antihypertensive drugs and renal denervation in the context of resistant hypertension.
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Affiliation(s)
- Omar Azzam
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
- Department of Nephrology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Sayeh Heidari Nejad
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
| | - Revathy Carnagarin
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
| | - Janis M Nolde
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
| | - Marcio Galindo-Kiuchi
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
- Department of Nephrology, Royal Perth Hospital, Perth, Western Australia, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
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Eirin A, Chade AR, Lerman LO. Kidney Intrinsic Mechanisms as Novel Targets in Renovascular Hypertension. Hypertension 2024; 81:206-217. [PMID: 37869904 PMCID: PMC10842320 DOI: 10.1161/hypertensionaha.123.21362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Almost a hundred years have passed since obstruction of the renal artery has been recognized to raise blood pressure. By now chronic renovascular disease (RVD) due to renal artery stenosis is recognized as a major source of renovascular hypertension and renal disease. In some patients, RVD unaccompanied by noteworthy renal dysfunction or blood pressure elevation may be incidentally identified during peripheral angiography. Nevertheless, in others, RVD might present as a progressive disease associated with diffuse atherosclerosis, leading to loss of renal function, renovascular hypertension, hemodynamic compromise, and a magnified risk for cardiovascular morbidity and mortality. Atherosclerotic RVD leads to renal atrophy, inflammation, and hypoxia but represents a potentially treatable cause of chronic renal failure because until severe fibrosis sets in the ischemic kidney, it retains a robust potential for vascular and tubular regeneration. This remarkable recovery capacity of the kidney begs for early diagnosis and treatment. However, accumulating evidence from both animal studies and randomized clinical trials has convincingly established the inadequate efficacy of renal artery revascularization to fully restore renal function or blood pressure control and has illuminated the potential of therapies targeted to the ischemic renal parenchyma to instigate renal regeneration. Some of the injurious mechanisms identified as potential therapeutic targets included oxidative stress, microvascular disease, inflammation, mitochondrial injury, and cellular senescence. This review recapitulates the intrinsic mechanisms that orchestrate renal damage and recovery in RVD and can be harnessed to introduce remedial opportunities.
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Affiliation(s)
- Alfonso Eirin
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Alejandro R. Chade
- Department of Medical Pharmacology and Physiology, University of Missouri-Columbia, MO
| | - Lilach O. Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
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Lee SN, Kim GH, Choi J, Kim MS. Case 8: A 58-Year-Old Man Presented With Symptomatic Recurrent Pulmonary Edema. J Korean Med Sci 2023; 38:e80. [PMID: 36918033 PMCID: PMC10010914 DOI: 10.3346/jkms.2023.38.e80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 02/07/2023] [Indexed: 03/06/2023] Open
Affiliation(s)
- Su Nam Lee
- Division of Cardiology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Gee-Hee Kim
- Division of Cardiology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Catholic Research Institute for Intractable Cardiovascular Disease (CRID), College of Medicine, The Catholic University of Korea, Seoul, Korea.
| | - Joonsung Choi
- Department of Radiology, St. Vincent's Hospital, School of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Min-Sik Kim
- Division of Cardiology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Dreyfus I, Zilinyin R, Radhakrishnann J, Parikh SA. Therapy for Renal Artery Stenosis: A Call for Change. J Endovasc Ther 2022:15266028221134884. [PMID: 36415917 DOI: 10.1177/15266028221134884] [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: 02/17/2024]
Abstract
CLINICAL IMPACT We present a brief case description of a patient who benefitted from stenting in ARAS and provide a comprehensive review of ARAS; its prevalence, pathophysiology, clinical manifestations, diagnosis and treatment. We review the evidence for and against stenting in ARAS as well as consensus guidelines for stenting. Our review is valuable as we argue that stenting in ARAS is underutilized and the randomized control data for stenting in those patients who may benefit most is lacking. Our review will provide an important perspective for clinicians faced with decisions of how to treat ARAS.
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Affiliation(s)
- Isaac Dreyfus
- Division of Cardiology, Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Robert Zilinyin
- Division of Cardiology, Department of Medicine, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Jai Radhakrishnann
- Division of Nephrology, Department of Medicine, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Sahil A Parikh
- Division of Cardiology, Department of Medicine, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
- Center for Interventional Cardiovascular Care and Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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Abstract
Hypertension is a major cause of cardiovascular morbidity and mortality globally. Many patients with hypertension have secondary causes of hypertension that merit further evaluation. For example, secondary hypertension can result in target organ damage to the heart, kidneys, and brain independent of the effects of blood pressure. Several causes benefit from targeted therapies to supplement first-line antihypertensive agents. However, secondary hypertension is often underrecognized. The goal of this review is to highlight optimal approaches to the diagnosis and management of common causes of secondary hypertension, including primary aldosteronism, renovascular hypertension, obstructive sleep apnea, and drug-induced hypertension.
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Affiliation(s)
- Harini Sarathy
- Division of Nephrology and Hypertension, Zuckerberg San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, San Francisco, CA 94110, USA. https://twitter.com/hurryknee
| | - Liann Abu Salman
- Renal-Electrolyte and Hypertension Division, Renal Division, Perelman School of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce Street, 1 Founders, Philadelphia, PA 19104, USA. https://twitter.com/LiannAbuSalman
| | - Christopher Lee
- Department of Medicine, Pennsylvania Hospital, University of Pennsylvania Health System, 800 Spruce Street, Philadelphia, PA 19104, USA. https://twitter.com/LeetopherC
| | - Jordana B Cohen
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, 831 Blockley, Philadelphia, PA 19104, USA; Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Correlation between Renal Artery Anatomy and Hypertension: A Retrospective Analysis of 3000 Patients. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2021:9957361. [PMID: 35003315 PMCID: PMC8731270 DOI: 10.1155/2021/9957361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 12/04/2021] [Accepted: 12/13/2021] [Indexed: 11/24/2022]
Abstract
Objective To assess the correlation between renal artery anatomy and blood pressure in Undiagnosed Hypertension and Diagnosed Hypertension. Methods The renal artery CT scanning imaging data and laboratory data of 3000 inpatients and outpatients were collected retrospectively in 4 centers of China. Morphometric parameters were assessed using the quantitative vascular analysis (unit: mM). Results 687 cases (23.2%) had accessory renal arteries unilaterally, and 216 cases (7.3%) had bilateral accessory renal arteries, including left kidney 825 (27.9%) and right kidney 798 (27.0%). The presence of accessory renal arteries and renal artery branches was higher in the diagnosed hypertension group as compared with the undiagnosed hypertension group (MARB, pp < 0.001; ARA, p < 0.001; others, p < 0.001). Consequently, multivariate regression analysis showed that age (OR = 2.519 (95% CI: 0.990–6.411, p < 0.001)), dyslipidemia (OR = 1.187 (95% CI: 0.960–1.454, p = 0.007)), renal hilum Outside the main renal artery branch (MRAB) (OR = 2.069 (95% CI: 1.614–2.524, p = 0.002)), and accessory renal artery (ARA) (OR = 2.071 (95% CI: 1.614–2.634, p = 0.001)) were risk factors of hypertension. In addition, higher renin activity was associated with ARA patients (2.19 ± 2.91 vs. 1.75 ± 2.85, p < 0.001). Conclusions When comparing renal arteries side by side, the anatomical length of the renal arteries is significantly different. In addition, the prevalence of accessory renal arteries and renal artery branches is higher in the hypertension group. The auxiliary renal artery and the main renal artery branch outside the renal portal are independent factors of hypertension. Renal sympathetic nerve activity is affected by renin activity and is related to the accessory renal artery.
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Primus C, Auer J. Bilateral renal artery stenosis in a young man. BMJ Case Rep 2021; 14:e237608. [PMID: 34389585 PMCID: PMC8365817 DOI: 10.1136/bcr-2020-237608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2021] [Indexed: 11/04/2022] Open
Abstract
A 34-year-old patient with a short history of severe hypertension was admitted to our hospital. Considering the young age and the severity of hypertension, we investigated the most common causes of secondary hypertension. Exposure to a single dose of an ACE inhibitor resulted in a rapid decline of the renal function. Further MRIrevealed a tight stenosis of both renal arteries closely to the ostium. In young patients, the most common cause of bilateral renal artery stenosis might be expected to be fibromuscular dysplasia. After recovery of renal function, invasive angiography, however, confirmed severe atherosclerotic lesion of both renal arteries. Therefore, angioplasty of both renal arteries was performed as a staged procedure. Hence, renal function showed rapid improvement and the patient had to be treated with a combination of a low-dose calcium antagonist and valsartan and especially a high-intensity statin.
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Affiliation(s)
- Carina Primus
- Cardiology, Saint Joseph's Hospital Braunau Department of Internal Medicine I, Braunau, Oberösterreich, Austria
| | - Johann Auer
- Department of Internal Medicine, Saint Joseph's Hospital Braunau Department of Internal Medicine I, Braunau, Oberösterreich, Austria
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Wang X, Wang S, Pang YP, Jiang T, Yu C, Li Y, Shi B. Contrast-Enhanced Ultrasound Assessment of Renal Parenchymal Perfusion in Patients with Atherosclerotic Renal Artery Stenosis to Predict Renal Function Improvement After Revascularization. Int J Gen Med 2020; 13:1713-1721. [PMID: 33408509 PMCID: PMC7781108 DOI: 10.2147/ijgm.s293316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 12/15/2020] [Indexed: 12/29/2022] Open
Abstract
Background Identifying patients with atherosclerotic renal artery stenosis (ARAS) who will be improved in renal function after percutaneous transluminal renal artery stenting (PTRAS) is crucial since most patients show no worthwhile benefit of PTRAS. Although the assessment of renal parenchymal perfusion is useful for the identification, few studies predict the renal functional improvement by evaluating the characteristics of renal perfusion. Objective The aim of this study was to assess the renal parenchymal perfusion in ARAS patients with contrast-enhanced ultrasonography (CEUS) and predict the benefits of renal function after PTRAS utilizing time-intensity curve (TIC) parameters. Methods Thirty-eight kidneys in 30 ARAS patients received PTRAS in this study. They were divided into moderate stenosis group (n=25) and severe stenosis group (n=13) and mild dysfunction group (n=14) and moderate dysfunction group (n=24) according to the degree of renal stenosis and radioisotope glomerular filtration rate (rGFR). The baseline assessment of renal function and renal parenchymal perfusion were performed for all patients. rGFR was repeated to evaluate the renal outcome at 4 months after PTRAS. The outcome of PTRAS was classified as improved, stable, or deteriorated compared to the baseline. Time-intensity curve (TIC) parameters obtained from CEUS were analyzed to evaluate the predictive accuracy. Results TIC parameters (AUC and PI) were positively correlated with renal function (r=0.617, 0.663; P<0.05) but weakly and negatively correlated with the stenosis (r=−0.360, −0.435; P<0.05). Baseline rGFR was not accurate in predicting improved renal function after PTRAS (0.670). The accuracy of the combined prediction model of baseline AUC and PI (0.889) was higher than the individual indicators (baseline AUC: 0.855 and PI: 0.782). Conclusion CEUS could accurately assess renal parenchymal perfusion and identify ARAS patients with potential benefit after PTRAS. The combination of TIC parameters (AUC and PI) is valuable in the prediction of improved renal function after PTRAS.
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Affiliation(s)
- Xiuyan Wang
- Department of Ultrasonography, Tongji Hospital of Tongji University, Shanghai, People's Republic of China
| | - Shuo Wang
- Department of Ultrasonography, Tongji Hospital of Tongji University, Shanghai, People's Republic of China
| | - Yan-Ping Pang
- Department of Ultrasonography, Tongji Hospital of Tongji University, Shanghai, People's Republic of China
| | - Tian Jiang
- Department of Ultrasonography, Tongji Hospital of Tongji University, Shanghai, People's Republic of China
| | - Chen Yu
- Department of Nephrology, Tongji Hospital of Tongji University, Shanghai, People's Republic of China
| | - Yuan Li
- Department of Ultrasonography, Tongji Hospital of Tongji University, Shanghai, People's Republic of China
| | - Baomin Shi
- Department of General Surgery, Tongji Hospital of Tongji University, Shanghai, People's Republic of China
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Hu X, Yang X, Li X, Luo D, Zhou Y, Dong H. Lipoprotein (a) as a residual risk factor for atherosclerotic renal artery stenosis in hypertensive patients: a hospital-based cross-sectional study. Lipids Health Dis 2020; 19:173. [PMID: 32703301 PMCID: PMC7379345 DOI: 10.1186/s12944-020-01272-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 04/29/2020] [Indexed: 12/24/2022] Open
Abstract
Background Low-density lipoprotein cholesterol (LDL-c) has been proven to be a risk factor for atherosclerotic cardiovascular disease (CVD), while lipoprotein (a) (Lp(a)) is a residual risk factor for CVD, even though LDL-c is well controlled by statin use. Importantly, the role of Lp(a) in atherosclerotic renal artery stenosis (ARAS) is still unknown. Methods For this hospital-based cross-sectional study, patients who simultaneously underwent coronary and renal angiography were examined. ARAS was defined as a 50% reduction in the cross-sectional (two-dimensional plane) area of the renal artery. Data were collected and compared between ARAS and non-ARAS groups, including clinical history and metabolite profiles. Univariate analysis, three tertile LDL-c-based stratified analysis, and multivariate-adjusted logistic analysis were conducted, revealing a correlation between Lp(a) and ARAS. Results A total of 170 hypertensive patients were included in this study, 85 with ARAS and 85 with non-RAS. Baseline information indicated comparability between the two groups. In the univariate and multivariate analysis, common risk factors for atherosclerosis were not significantly different. Stratified analysis of LDL-c revealed a significant increase in the incidence of ARAS in patients who had high Lp(a) concentrations at low LDL-c levels (odds ratio (OR): 4.77, 95% confidence interval (CI): 1.04–21.79, P = 0.044). Further logistic analysis with adjusted covariates also confirmed the result, indicating that high Lp(a) levels were independently associated with ARAS (adjusted OR (aOR): 6.14, 95%CI: 1.03–36.47, P = 0.046). This relationship increased with increasing Lp(a) concentration based on a curve fitting graph. These results were not present in the low and intermediate LDL-c-level groups. Conclusion In hypertensive patients who present low LDL-c, high Lp(a) was significantly associated with atherosclerotic renal artery stenosis and thus is a residual risk factor.
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Affiliation(s)
- Xiangming Hu
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, #96 Dongchuan Road, Guangzhou, 510080, Guangdong, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Xing Yang
- Department of Cardiology, Guangdong Provincial People's Hospital Zhuhai Hospital (Zhuhai Golden Bay Center Hospital), Zhuhai, 519040, Guangdong, China
| | - Xida Li
- Department of Cardiology, Guangdong Provincial People's Hospital Zhuhai Hospital (Zhuhai Golden Bay Center Hospital), Zhuhai, 519040, Guangdong, China
| | - Demou Luo
- Department of Cardiology, Vascular Center, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, #96 Dongchuan Road, Guangzhou, 510080, Guangdong, China
| | - Yingling Zhou
- Department of Cardiology, Vascular Center, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, #96 Dongchuan Road, Guangzhou, 510080, Guangdong, China.
| | - Haojian Dong
- Department of Cardiology, Vascular Center, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, #96 Dongchuan Road, Guangzhou, 510080, Guangdong, China.
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Wang Q, Li X, Liu Z, Xu J, Han Y, Yu T, Chen S, Tang Y, Liu Y, Li X. Diagnosis and Treatment of Renal Artery Stenosis in China in the Era of Donation After Cardiac Death. Ann Transplant 2020; 25:e918076. [PMID: 32015300 PMCID: PMC7023544 DOI: 10.12659/aot.918076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background The aim of this study was to investigate the clinical features and treatment strategies of transplant renal artery stenosis (TRAS) with kidneys from donation after cardiac death (DCD). Material/Methods We collected the clinical data of donors and recipients of single-center DCD-induced TRAS from January 2015 to June 2017. Results All the 8 cases of TRAS were from hypertensive cerebrovascular accident DCD-originated kidneys. The mean donor age was 53.5 (45~57) years, with mean BMI 27.8 (26.4~32.3) kg/m2, atherosclerosis index 5.8 (4.9~7.0), and renal atherosclerotic plaque. Clinical features of TRAS were: refractory hypertension with elevated serum creatinine >50%, and negative urine protein and occult blood. Ultrasound of transplanted kidneys showed renal blood flow index 0.49 (0.43~0.55). Angiography confirmed the diagnosis of renal artery trunk or secondary branch stenosis. There were 2 cases of moderate stenosis and 6 cases of severe stenosis. Six patients underwent stent implantation and 2 patients underwent balloon dilatation. Seven patients had serum creatinine recovery after interventional therapy during follow-up. The transplanted kidney of 1 patient ruptured 6 h after interventional therapy and was then resected. Conclusions The incidence of TRAS with hypertensive cerebrovascular accident DCD-originated kidneys is relatively high, which is a warning to kidney transplant physicians. Digital subtraction angiography (DSA) is the most reliable diagnostic means of TRAS and can be performed concurrently with intervention therapy. If the donor has severe atherosclerosis, plaques that are visible to the unaided eye in the renal artery trunk should be removed as completely as possible.
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Affiliation(s)
- Qiang Wang
- Department of Urology, Beijing Friendship Hospital, Capital Medical University, Beijing, China (mainland)
| | - Xiaoli Li
- Department of Geriatric Cardiology, The 8TH Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Zhijia Liu
- Organ Transplant Institute, The 8TH Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Junnan Xu
- Organ Transplant Institute, The 8TH Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Yong Han
- Organ Transplant Institute, The 8TH Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Tao Yu
- Organ Transplant Institute, The 8TH Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Song Chen
- Department of Urology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China (mainland)
| | - Yuzhe Tang
- Department of Urology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China (mainland)
| | - Yubao Liu
- Department of Urology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China (mainland)
| | - Xiang Li
- Organ Transplant Institute, The 8TH Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
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Selective intrarenal delivery of mesenchymal stem cell-derived extracellular vesicles attenuates myocardial injury in experimental metabolic renovascular disease. Basic Res Cardiol 2020; 115:16. [PMID: 31938859 DOI: 10.1007/s00395-019-0772-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 12/27/2019] [Indexed: 02/07/2023]
Abstract
Extracellular vesicles (EVs) deliver genes and proteins to recipient cells, and mediate paracrine actions of their parent cells. Intrarenal delivery of mesenchymal stem cell (MSC)-derived EVs preserves stenotic-kidney function and reduces release of pro-inflammatory cytokines in a swine model of coexisting metabolic syndrome (MetS) and renal artery stenosis (RAS). We hypothesized that this approach is also capable of blunting cardiac injury and dysfunction. Five groups of pigs were studied after 16 weeks of diet-induced MetS and RAS (MetS + RAS), MetS and MetS + RAS treated 4 weeks earlier with a single intrarenal delivery of EVs-rich fraction harvested from autologous adipose tissue-derived MSCs, and lean and MetS Shams. Cardiac structure, function, and myocardial oxygenation were assessed in vivo using imaging, and cardiac inflammation, senescence, and fibrosis ex vivo. Inflammatory cytokine levels were measured in circulating and renal vein blood. Intrarenal EV delivery improved stenotic-kidney glomerular filtration rate and renal blood flow, and decreased renal release of monocyte-chemoattractant protein-1 and interleukin-6. Furthermore, despite unchanged systemic hemodynamics, intrarenal EV delivery in MetS + RAS normalized cardiac diastolic function, attenuated left ventricular remodeling, cellular senescence and inflammation, and improved myocardial oxygenation and capillary density in MetS + RAS. Intrarenal delivery of MSC-derived EVs blunts myocardial injury in experimental MetS + RAS, possibly related to improvement in renal function and systemic inflammatory profile. These observations underscore the central role of inflammation in the crosstalk between the kidney and heart, and the important contribution of renal function to cardiac structural and functional integrity in coexisting MetS and RAS.
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Abstract
Renovascular disease (RVD) is a major cause of secondary hypertension. Atherosclerotic renal artery stenosis is the most common type of RVD followed by fibromuscular dysplasia. It has long been recognized as the prototype of angiotensin-dependent hypertension. However, the mechanisms underlying the physiopathology of hypertensive occlusive vascular renal disease are complex and distinction between the different causes of RVD should be made. Recognition of these distinct types of RVD with different degrees of renal occlusive disease is important for management. The greatest challenge is to individualize and implement the best approach for each patient in the setting of widely different comorbidities.
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Affiliation(s)
- Sandra M Herrmann
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55902, USA.
| | - Stephen C Textor
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55902, USA
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Lauder L, Ewen S, Tzafriri AR, Edelman ER, Lüscher TF, Blankenstijn PJ, Dörr O, Schlaich M, Sharif F, Voskuil M, Zeller T, Ukena C, Scheller B, Böhm M, Mahfoud F. Renal artery anatomy assessed by quantitative analysis of selective renal angiography in 1,000 patients with hypertension. EUROINTERVENTION 2019; 14:121-128. [PMID: 29633939 DOI: 10.4244/eij-d-18-00112] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
AIMS With increasing attention to renovascular causes and targets for hypertension there arises a critical need for more detailed knowledge of renal arterial anatomy. However, a standardised nomenclature is lacking. The present study sought to develop a standardised nomenclature for renal anatomy considering the complexity and variation of the renal arterial tree and to assess the applicability of the nomenclature. METHODS AND RESULTS One thousand hypertensive patients underwent invasive selective renal artery angiography in nine centres. Further, renovasography was performed in 249 healthy swine as a surrogate for normotensive anatomy. Anatomical parameters were assessed by quantitative vascular analysis. Patients' mean blood pressure was 168/90±26/17 mmHg. The right main renal artery was longer than the left (41±15 mm vs. 35±13 mm, p<0.001), but the left had a greater diameter (5.4±1.2 vs. 5.2±1.2 mm, p<0.001). Accessory renal arteries and renal artery disease were documented in 22% and 9% of the patients, respectively. Other than exhibiting a longer left main renal artery in uncontrolled hypertensives (+2.7 mm, p=0.034) there was no anatomical difference between patients with controlled and uncontrolled hypertension. Main renal artery mean diameter was smaller in patients with impaired kidney function (GFR <90 ml/min, left -0.5 mm, right -0.4 mm, both p<0.001). CONCLUSIONS Renal arterial anatomy differs between sides but shows no difference between patients with and without blood pressure control. Impaired GFR was associated with small main renal artery diameter.
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Affiliation(s)
- Lucas Lauder
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Universität des Saarlandes, Homburg/Saar, Germany
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16
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Deshmukh H, Barker E, Anbarasan T, Levin D, Bell S, Witham MD, George J. Calcium channel blockers are associated with improved survival and lower cardiovascular mortality in patients with renovascular disease. Cardiovasc Ther 2018; 36:e12474. [PMID: 30372589 DOI: 10.1111/1755-5922.12474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/11/2018] [Accepted: 10/19/2018] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Results of interventional trials in renovascular hypertension have been disappointing, and medical therapy is the current recommended gold standard. However, the comparative long-term benefits of different antihypertensive drug classes in atherosclerotic renal artery stenosis are not known. We aim to assess the effect of different antihypertensive drug classes on outcomes in renovascular hypertension DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: Using Tayside Health Informatics Centre database, anonymized data over a 6-year period was analyzed. Biochemistry, prescribing data, morbidity, mortality, and demographic data were accessed via hospital medical records and electronic data stored in the Tayside Health Informatics Centre Safe Haven. General Registrar's Office data were used to identify patients who died from cardiovascular disease. Independent predictors of survival in each group were analyzed using Kaplan-Meier survival curves and Cox proportional hazard models, adjusted for a range of covariates, using time-updated drug analysis. Blood pressure data were obtained from primary and secondary care clinic blood pressure records for each patient. Adjustments for mean systolic blood pressure over the follow-up period and baseline blood pressure were made. RESULTS A total of 579 patients with atherosclerotic renal artery stenosis were identified. In the unilateral renal artery stenosis cohort, calcium channel blockers but not ACE inhibitors/ARBs were associated with a significant reduction in all-cause (HR = 0.45, CI = 0.31, 0.65; P = <0.0001) and cardiovascular (HR = 0.51, CI = 0.29-0.90 P = 0.019) mortality. This was maintained after adjustment for blood pressure. In the bilateral renal artery stenosis cohort, both classes of drugs reduced all-cause but not cardiovascular mortality. Patients with moderate disease benefitted more than those with mild or severe disease. CONCLUSIONS Calcium channel blockers are associated with significantly increased survival and lower cardiovascular mortality particularly in patients with moderate RAS disease.
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Affiliation(s)
- Harshal Deshmukh
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, Dundee, UK
| | - Emma Barker
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, Dundee, UK
| | | | - Daniel Levin
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, Dundee, UK
| | - Samira Bell
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, Dundee, UK
| | - Miles D Witham
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, Dundee, UK
| | - Jacob George
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, Dundee, UK
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Pellegrin M, Bouzourène K, Aubert JF, Nahimana A, Duchosal MA, Mazzolai L. Activation of Bone Marrow-Derived Cells Angiotensin (Ang) II Type 1 Receptor by Ang II Promotes Atherosclerotic Plaque Vulnerability. Int J Mol Sci 2018; 19:ijms19092621. [PMID: 30181481 PMCID: PMC6163751 DOI: 10.3390/ijms19092621] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 08/24/2018] [Accepted: 08/31/2018] [Indexed: 02/08/2023] Open
Abstract
Angiotensin (Ang) II triggers vulnerable atherosclerotic plaque development. Bone marrow (BM)-derived cells are key players in atherogenesis but whether Ang II induces plaque vulnerability directly through Ang II type 1 receptor (AT1R) activation on these cells remains to be clarified. In the present study, we investigated whether a lack of AT1R on BM-derived cells might affect Ang II-mediated vulnerable plaque development. The 2-kidney, 1-clip (2K1C) model (Ang II-dependent mouse model of advanced atherosclerosis and vulnerable plaques) was generated in ApoE−/− mice transplanted with AT1aR−/− or AT1aR+/+ BM. Plasma cholesterol as well as hepatic mRNA expression levels of genes involved in cholesterol metabolism were significantly lower in 2K1C mice transplanted with AT1aR−/− BM than in controls. Atherosclerotic lesions were significantly smaller in AT1aR−/− BM 2K1C mice (−79% in the aortic sinus and −71% in whole aorta compared to controls). Plaques from AT1aR−/− BM 2K1C mice exhibited reduced lipid core/fibrous cap and macrophage/smooth muscle cells ratios (−82% and −88%, respectively), and increased collagen content (+70%), indicating a more stable phenotype. Moreover, aortic mRNA levels of pro-inflammatory cytokines IL-12p35, IL-1β, and TNF-α were significantly reduced in AT1aR−/− BM 2K1C mice. No significant differences in either the number of circulating Ly6Chigh inflammatory monocytes and Ly6Clow resident anti-inflammatory monocyte subsets, or in mRNA levels of aortic M1 or M2 macrophage markers were observed between the two groups. No significant differences were observed in splenic mRNA levels of T cell subsets (Th1, Th2, Th17 and Treg) markers between the two groups. In conclusion, direct AT1R activation by Ang II on BM-derived cells promotes hepatic mRNA expression of cholesterol-metabolism-related genes and vascular mRNA expression of pro-inflammatory cytokines that may lead to plaque instability.
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Affiliation(s)
- Maxime Pellegrin
- Division of Angiology, Heart and Vessel Department, Lausanne University Hospital, 1011 Lausanne, Switzerland.
| | - Karima Bouzourène
- Division of Angiology, Heart and Vessel Department, Lausanne University Hospital, 1011 Lausanne, Switzerland.
| | - Jean-François Aubert
- Division of Angiology, Heart and Vessel Department, Lausanne University Hospital, 1011 Lausanne, Switzerland.
| | - Aimable Nahimana
- Service and Central Laboratory of Hematology, LABORATORY and Oncology DepartmentS, Lausanne University Hospital, 1011 Lausanne, Switzerland.
| | - Michel A Duchosal
- Service and Central Laboratory of Hematology, LABORATORY and Oncology DepartmentS, Lausanne University Hospital, 1011 Lausanne, Switzerland.
| | - Lucia Mazzolai
- Division of Angiology, Heart and Vessel Department, Lausanne University Hospital, 1011 Lausanne, Switzerland.
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18
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Xiong HL, Peng M, Jiang XJ, Che WQ, Dong H, Chen Y, Zou YB, Gao RL, Liu LS. Time trends regarding the etiology of renal artery stenosis: 18 years' experience from the China Center for Cardiovascular Disease. J Clin Hypertens (Greenwich) 2018; 20:1302-1309. [PMID: 30027575 DOI: 10.1111/jch.13356] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 05/19/2018] [Accepted: 06/07/2018] [Indexed: 01/11/2023]
Abstract
The time trends regarding the etiology of renal artery stenosis (RAS) are changing, but few investigations have focused on these issues. This study aimed to analyze the time trends regarding the etiology of RAS in a large patient sample from the China Center for Cardiovascular Disease. Consecutive inpatients with RAS from January 1999 to December 2016 were enrolled in this study. The etiologic diagnosis of RAS was based on established criteria. We retrospectively analyzed the time trends regarding the etiology of RAS during an 18-year period. A total of 2905 patients with RAS were enrolled. There were 2393 (82.4%) patients with atherosclerosis (AS), 345 (11.9%) with Takayasu arteritis (TA), 126 (4.3%) with fibromuscular dysplasia (FMD), and 41 (1.4%) with other causes. Among all patients (n = 2905), patients aged ≤ 40 years (n = 450), patients aged >40 years (n = 2455), female patients (n = 1097), male patients (n = 1808), female patients aged >40 years (n = 808), and male patients aged >40 years (n = 1647), there were a gradual increase in the proportion of atherosclerotic RAS (P < 0.05), a gradual decrease in the proportion of RAS caused by TA (P < 0.05), and almost no change in the proportion of RAS caused by FMD during the 18-year period (P > 0.05). The data show that the primary causes of RAS are AS, TA, and FMD. The proportion of RAS caused by AS and TA gradually increased and decreased, respectively, over time, and the proportion of RAS caused by FMD showed no significant change.
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Affiliation(s)
- Hong-Liang Xiong
- Department of Cardiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Meng Peng
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiong-Jing Jiang
- Department of Cardiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wu-Qiang Che
- Department of Cardiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Dong
- Department of Cardiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Chen
- Department of Cardiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu-Bao Zou
- Department of Cardiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Run-Lin Gao
- Department of Cardiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li-Sheng Liu
- Department of Cardiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Atherosclerotic renovascular disease - epidemiology, treatment and current challenges. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2017; 13:191-201. [PMID: 29056991 PMCID: PMC5644037 DOI: 10.5114/aic.2017.70186] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 09/16/2017] [Indexed: 12/30/2022] Open
Abstract
The neutral results of recent large randomized controlled trials comparing renal revascularization with optimal medical therapy in patients with atherosclerotic renovascular disease (ARVD) have cast doubt on the role of revascularization in the management of unselected patients with this condition. However, these studies have strengthened the evidence base for the role of contemporary intensive medical vascular protection therapy and aggressive risk factor control in improving clinical outcomes in ARVD. Patients presenting with ‘high-risk’ clinical features such as uncontrolled hypertension, rapidly declining renal function or flash pulmonary oedema are underrepresented in these studies; hence these results may not be applicable to all patients with ARVD. In this ‘high-risk’ subgroup, conservative management may not be sufficient in preventing adverse events, and indeed, observational evidence suggests that this specific patient subgroup may gain benefit from timely renal revascularization. Current challenges include the development of novel diagnostic techniques to establish haemodynamic significance of a stenosis, patient risk stratification and prediction of post-revascularization outcomes to ultimately facilitate patient selection for revascularization. In this paper we describe the epidemiology of this condition and discuss treatment recommendations for this condition in light of the results of recent randomized controlled trials while highlighting important clinical unmet needs and challenges faced by clinicians managing this condition.
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20
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Ritchie J, Green D, Chrysochou T, Hegarty J, Handley K, Ives N, Wheatley K, Houston G, Wright J, Neyses L, Chalmers N, Mark P, Patel R, Moss J, Roditi G, Eadington D, Lukaschuk E, Cleland J, Kalra PA. Effect of renal artery revascularization upon cardiac structure and function in atherosclerotic renal artery stenosis: cardiac magnetic resonance sub-study of the ASTRAL trial. Nephrol Dial Transplant 2017; 32:1006-1013. [PMID: 27257278 DOI: 10.1093/ndt/gfw107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 04/09/2016] [Indexed: 11/13/2022] Open
Abstract
Background Cardiac abnormalities are frequent in patients with atherosclerotic renovascular disease (ARVD). The Angioplasty and Stenting for Renal Artery Lesions (ASTRAL) trial studied the effect of percutaneous renal revascularization combined with medical therapy compared with medical therapy alone in 806 patients with ARVD. Methods This was a pre-specified sub-study of ASTRAL (clinical trials registration, current controlled trials number: ISRCTN59586944), designed to consider the effect of percutaneous renal artery angioplasty and stenting on change in cardiac structure and function, measured using cardiac magnetic resonance (CMR) imaging. Fifty-one patients were recruited from six selected ASTRAL centres. Forty-four completed the study (medical therapy n = 21; revascularization n = 23). Full analysis of CMR was possible in 40 patients (18 medical therapy and 22 revascularization). CMR measurements of left and right ventricular end systolic (LV and RVESV) and diastolic volume (LV and RVEDV), ejection fraction (LVEF) and mass (LVM) were made shortly after recruitment and before revascularization in the interventional group, and again after 12 months. Reporting was performed by CMR analysts blinded to randomization arm. Results Groups were well matched for mean age (70 versus 72 years), blood pressure (148/71 versus 143/74 mmHg), degree of renal artery stenosis (75 versus 75%) and comorbid conditions. In both randomized groups, improvements in cardiac structural parameters were seen at 12 months, but there were no significant differences between treatment groups. Median left ventricular changes between baseline and 12 months (medical versus revascularization) were LVEDV -1.9 versus -5.8 mL, P = 0.4; LVESV -2.1 versus 0.3 mL, P = 0.7; LVM -5.4 versus -6.3 g, P = 0.8; and LVEF -1.5 versus -0.8%, P = 0.7. Multivariate regression also found that randomized treatment assignment was not associated with degree of change in any of the CMR measurements. Conclusions In this sub-study of the ASTRAL trial, renal revascularization did not offer additional benefit to cardiac structure or function in unselected patients with ARVD.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Patrick Mark
- Queen Elizabeth University Hospital, Govan, Glasgow, UK
| | - Rajan Patel
- Queen Elizabeth University Hospital, Govan, Glasgow, UK
| | - Jon Moss
- Queen Elizabeth University Hospital, Govan, Glasgow, UK
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21
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Jiang X, Peng M, Li B, Dong H, Che W, Zou Y, Yang Y, Gao R. The efficacy of renal artery stent combined with optimal medical therapy in patients with severe atherosclerotic renal artery stenosis. Curr Med Res Opin 2016; 32:3-7. [PMID: 27779455 DOI: 10.1080/03007995.2016.1218833] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To evaluate the efficacy of renal artery stent combined with optimal medical therapy as treatment for renal artery stenosis. RESEARCH DESIGN AND METHODS A prospective cohort study was conducted. Patients with severe atherosclerotic renal artery stenosis received percutaneous renal artery stent because of poorly controlled hypertension or preservation of renal function. The patients also received optimal medical therapy to achieve the blood pressure, lipid and blood glucose targets. MAIN OUTCOME MEASURES All patients underwent a 12 month follow-up to observe the effect of the procedure on blood pressure control, number of antihypertensive medications and creatinine level. RESULTS Stents were placed in 185 renal arteries of 149 patients. Mean stenosis was 83.1 ± 7.0%. The success rate of renal artery stent was 99.3%. At 12 months, estimated glomerular filtration rate increased significantly compared with baseline (84.1 ± 28.8 vs. 76.5 ± 22.50 ml/min ×1.73 m2, p < 0.05). Both office blood pressure and 24 hour blood pressure significantly decreased compared with baseline (from 153/83 mmHg to 134/73 mmHg and from 143/80 mmHg to 124/69 mmHg, respectively; p < 0.05), and less antihypertensive medication was taken compared with baseline (1.5 ± 0.8 vs. 2.2 ± 0.9; p < 0.05). CONCLUSIONS Renal artery stent combined with optimal medical therapy as a treatment has a beneficial effect on blood pressure control and estimated glomerular filtration rate in selected patients with atherosclerotic renal artery stenosis. Larger studies with a longer follow-up appear necessary to further confirm these intriguing findings.
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Affiliation(s)
- Xiongjing Jiang
- a Department of Cardiology , Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Meng Peng
- a Department of Cardiology , Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Bin Li
- a Department of Cardiology , Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Hui Dong
- a Department of Cardiology , Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Wuqiang Che
- a Department of Cardiology , Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Yubao Zou
- a Department of Cardiology , Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Yuejin Yang
- a Department of Cardiology , Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Runlin Gao
- a Department of Cardiology , Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
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Renovascular heart failure: heart failure in patients with atherosclerotic renal artery disease. Cardiovasc Interv Ther 2016; 31:171-82. [PMID: 27052017 DOI: 10.1007/s12928-016-0392-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 03/18/2016] [Indexed: 10/22/2022]
Abstract
Atherosclerotic renal artery disease presents with a broad spectrum of clinical features, including heart failure as well as hypertension, and renal failure. Although recent randomized controlled trials failed to demonstrate renal artery stenting can reduce blood pressure or the number of cardiovascular or renal events more so than medical therapy, increasing attention has been paid to flash pulmonary edema and congestive heart failure associated with atherosclerotic renal artery disease. This clinical entity "renovascular heart failure" is diagnosed retrospectively. Given the increasing global burden of heart failure, this review highlights the background and catheter-based therapeutic aspects for renovascular heart failure.
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Andersson M, Jägervall K, Eriksson P, Persson A, Granerus G, Wang C, Smedby Ö. How to measure renal artery stenosis--a retrospective comparison of morphological measurement approaches in relation to hemodynamic significance. BMC Med Imaging 2015; 15:42. [PMID: 26459634 PMCID: PMC4601150 DOI: 10.1186/s12880-015-0086-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 09/23/2015] [Indexed: 11/26/2022] Open
Abstract
Background Although it is well known that renal artery stenosis may cause renovascular hypertension, it is unclear how the degree of stenosis should best be measured in morphological images. The aim of this study was to determine which morphological measures from Computed Tomography Angiography (CTA) and Magnetic Resonance Angiography (MRA) are best in predicting whether a renal artery stenosis is hemodynamically significant or not. Methods Forty-seven patients with hypertension and a clinical suspicion of renovascular hypertension were examined with CTA, MRA, captopril-enhanced renography (CER) and captopril test (Ctest). CTA and MRA images of the renal arteries were analyzed by two readers using interactive vessel segmentation software. The measures included minimum diameter, minimum area, diameter reduction and area reduction. In addition, two radiologists visually judged the diameter reduction without automated segmentation. The results were then compared using limits of agreement and intra-class correlation, and correlated with the results from CER combined with Ctest (which were used as standard of reference) using receiver operating characteristics (ROC) analysis. Results A total of 68 kidneys had all three investigations (CTA, MRA and CER + Ctest), where 11 kidneys (16.2 %) got a positive result on the CER + Ctest. The greatest area under ROC curve (AUROC) was found for the area reduction on MRA, with a value of 0.91 (95 % confidence interval 0.82–0.99), excluding accessory renal arteries. As comparison, the AUROC for the radiologists’ visual assessments on CTA and MRA were 0.90 (0.82–0.98) and 0.91 (0.83–0.99) respectively. None of the differences were statistically significant. Conclusions No significant differences were found between the morphological measures in their ability to predict hemodynamically significant stenosis, but a tendency of MRA having higher AUROC than CTA. There was no significant difference between measurements made by the radiologists and measurements made with fuzzy connectedness segmentation. Further studies are required to definitely identify the optimal measurement approach.
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Affiliation(s)
- Malin Andersson
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden. .,Department of Radiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
| | - Karl Jägervall
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden. .,Department of Radiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
| | - Per Eriksson
- Department of Nephrology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
| | - Anders Persson
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden. .,Department of Radiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
| | - Göran Granerus
- Department of Clinical Physiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
| | - Chunliang Wang
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden. .,Department of Radiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden. .,School of Technology and Health (STH), KTH Royal Institute of Technology, Stockholm, Sweden.
| | - Örjan Smedby
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden. .,Department of Radiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden. .,School of Technology and Health (STH), KTH Royal Institute of Technology, Stockholm, Sweden.
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Peng M, Jiang XJ, Dong H, Zou YB, Zhang HM, Song L, Li B, Yang YJ, Wu HY, Gao RL, Zhang WG, Liu LS. Etiology of renal artery stenosis in 2047 patients: a single-center retrospective analysis during a 15-year period in China. J Hum Hypertens 2015; 30:124-8. [PMID: 25947274 DOI: 10.1038/jhh.2015.40] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 03/09/2015] [Accepted: 03/25/2015] [Indexed: 12/12/2022]
Abstract
Systematic investigation with large sample size of the distribution of etiologies of renal artery stenosis (RAS) is scant in both Western countries and China. We retrospectively analyzed the etiology of RAS in 2047 consecutive inpatients diagnosed with RAS for hypertension at Fuwai Hospital between 1999 and 2014. The number of patients with atherosclerosis was 1668 (81.5%), 259 (12.7%) with Takayasu's arteritis (TA), 86 (4.2%) with fibromuscular dysplasia (FMD), 34 (1.6%) with other causes. There was an obvious increase with age in the proportion of atherosclerotic RAS (P<0.001). In patients aged ⩽40 years (n=319) the predominant etiology of RAS was TA (60.5%), followed by FMD (24.8%). In patients aged >40 years (n=1728) the major cause of RAS was atherosclerosis (94.7%), followed by TA (3.8%).The proportion of TA and FMD in female patients was significantly higher than that in male patients (P<0.001). In female patients aged ⩽40 years (n=215), the top three etiologies of RAS were TA (68.4%), FMD (27.9%) and atherosclerosis (1.4%). The present analysis showed that atherosclerosis, TA and FMD were sequentially the top three causes of RAS in the National Center of China. Age and gender had a significant effect on the distribution of etiologies of RAS.
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Affiliation(s)
- M Peng
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - X-J Jiang
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - H Dong
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Y-B Zou
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - H-M Zhang
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - L Song
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - B Li
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Y-J Yang
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - H-Y Wu
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - R-L Gao
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - W-G Zhang
- DSM Nutritional Products, Human Nutrition and Health, Beijing, China
| | - L-S Liu
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Pagliaro B, Tocci G, Pagannone E, Musumeci MB, Testa M, Sensini I, Autore C, Ferrucci A, Volpe M. An atypical clinical presentation of renovascular hypertension. Int J Cardiol 2014; 177:e107-10. [PMID: 25300660 DOI: 10.1016/j.ijcard.2014.09.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Accepted: 09/20/2014] [Indexed: 11/19/2022]
Affiliation(s)
- Beniamino Pagliaro
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome "Sapienza", Sant'Andrea Hospital, Rome, Italy
| | - Giuliano Tocci
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome "Sapienza", Sant'Andrea Hospital, Rome, Italy; IRCCS Neuromed, Pozzilli, IS, Italy
| | - Erika Pagannone
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome "Sapienza", Sant'Andrea Hospital, Rome, Italy
| | - M Beatrice Musumeci
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome "Sapienza", Sant'Andrea Hospital, Rome, Italy
| | - Marco Testa
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome "Sapienza", Sant'Andrea Hospital, Rome, Italy
| | - Isabella Sensini
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome "Sapienza", Sant'Andrea Hospital, Rome, Italy
| | - Camillo Autore
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome "Sapienza", Sant'Andrea Hospital, Rome, Italy
| | - Andrea Ferrucci
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome "Sapienza", Sant'Andrea Hospital, Rome, Italy
| | - Massimo Volpe
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome "Sapienza", Sant'Andrea Hospital, Rome, Italy; IRCCS Neuromed, Pozzilli, IS, Italy.
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Where now in the management of renal artery stenosis? Implications of the ASTRAL and CORAL trials. Curr Opin Nephrol Hypertens 2014; 23:525-32. [DOI: 10.1097/mnh.0000000000000059] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Bikbov B, Perico N, Remuzzi G. High serum cholesterol: a missed risk factor for chronic kidney disease mortality. Lancet Diabetes Endocrinol 2014; 2:613-4. [PMID: 25182460 DOI: 10.1016/s2213-8587(14)70162-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Boris Bikbov
- Chair of Nephrology, AI Evdokimov Moscow State University of Medicine and Dentistry, Moscow 127463, Russia; Department of Nephrology Issues of Transplanted Kidney, Academician VI Shumakov Federal Research Center of Transplantology and Artificial Organs, Moscow, Russia; Moscow City Nephrology Center, Moscow City Hospital 52, Moscow, Russia.
| | - Norberto Perico
- Istituto di Ricerche Farmacologiche Mario Negri (IRCCS), Bergamo, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri (IRCCS), Bergamo, Italy; Unit of Nephrology, Dialysis and Transplantation, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
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Ezzati M, Danaei G. High serum cholesterol: a missed risk factor for chronic kidney disease mortality--authors' reply. Lancet Diabetes Endocrinol 2014; 2:614. [PMID: 25182461 DOI: 10.1016/s2213-8587(14)70165-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Majid Ezzati
- MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, London W2 1PG, UK.
| | - Goodarz Danaei
- Department of Global Health and Poulation, Harvard School of Public Health, Boston, MA, USA; Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
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29
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Association between herpes zoster and end stage renal disease entrance in chronic kidney disease patients: a population-based cohort study. Eur J Clin Microbiol Infect Dis 2014; 33:1809-15. [DOI: 10.1007/s10096-014-2143-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 04/24/2014] [Indexed: 10/25/2022]
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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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31
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van den Berg DT, Deinum J, Postma CT, van der Wilt GJ, Riksen NP. The efficacy of renal angioplasty in patients with renal artery stenosis and flash oedema or congestive heart failure: a systematic review. Eur J Heart Fail 2014; 14:773-81. [DOI: 10.1093/eurjhf/hfs037] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | | | | | - Niels P. Riksen
- Department of Internal Medicine
- Pharmacology-Toxicoloy; Radboud University Nijmegen Medical Centre; PO Box 9101 6500 HB Nijmegen The Netherlands
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Eirin A, Lerman LO. Darkness at the end of the tunnel: poststenotic kidney injury. Physiology (Bethesda) 2013; 28:245-53. [PMID: 23817799 DOI: 10.1152/physiol.00010.2013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Renal artery stenosis remains an important contributor to renal failure in the elderly population, but uncertainty continues to surround the mechanisms underlying progressive renal dysfunction. Here, we present the current understanding of the pathogenic mechanisms responsible for renal injury in these patients, with emphasis on those involved in disease progression.
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Affiliation(s)
- Alfonso Eirin
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
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Lim SW, Chrysochou C, Buckley DL, Kalra PA, Sourbron SP. Prediction and assessment of responses to renal artery revascularization with dynamic contrast-enhanced magnetic resonance imaging: a pilot study. Am J Physiol Renal Physiol 2013; 305:F672-8. [PMID: 23804449 DOI: 10.1152/ajprenal.00007.2013] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The aim of this study was to assess the potential of dynamic contrast-enhanced (DCE) MRI to predict and evaluate functional outcomes after renal artery revascularization for renal artery stenosis (RAS). The single-kidney glomerular filtration rate (SK-GFR) was measured in 15 patients with atherosclerotic RAS with DCE-MRI and radioisotopes at baseline and 4 mo after revascularization. DCE-MRI also produced measurements of blood flow, blood volume, extraction fraction, tubular transit time, and functional volume. Stented kidneys (n = 22) were divided into three response groups on the basis of the changes in radioisotope SK-GFR: improved (n = 5), stable (n = 13), and deteriorated (n = 4). A good agreement was found between SK-GFR values from DCE-MRI and radioisotopes (correlation coefficient: 0.91). Before intervention, kidneys that improved had lower extraction fraction, higher blood volume, longer tubular transit time, and lower SK-GFR. After intervention, improved kidneys had increased functional volume, and deteriorated kidneys had reduced functional volume and extraction fraction. Revascularization improved blood flow and blood volume in all groups. This pilot study led to the hypothesis that well-vascularized kidneys with reduced extraction fractions are most likely to benefit from revascularization. More generally, DCE-MRI has the potential to replace radioisotope measurement of SK-GFR and may improve patient management by providing additional information on tissue perfusion.
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Affiliation(s)
- Su Wei Lim
- Div. of Medical Physics, Univ. of Leeds, Level 8, Worsley Bldg., Leeds LS2 9JT, UK
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Fang CC, Chen WJ, Peng CL, Chen PC, Chien KL, Tsai TJ, Lee YT. Renovascular disease in Taiwan: a long-term nationwide population study. Int J Cardiol 2013; 168:541-2. [PMID: 23523252 DOI: 10.1016/j.ijcard.2013.01.236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 01/13/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Cheng-Chung Fang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; National Taiwan University College of Medicine, Taipei, Taiwan
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Alonso JV, Caballero RM, Lopera EL, Avalos FC, Navarro C. Flash pulmonary edema and renal artery stenosis: pickering syndrome. Am J Emerg Med 2013; 31:454.e1-4. [DOI: 10.1016/j.ajem.2012.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 07/09/2012] [Indexed: 10/27/2022] Open
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Iseki K, Iseki C, Kurahashi I, Watanabe T. Effect of glomerular filtration rate and proteinuria on medical cost among screened subjects. Clin Exp Nephrol 2012. [PMID: 23180040 DOI: 10.1007/s10157-012-0718-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Chronic kidney disease is a predictor of end-stage renal disease (ESRD) and cardiovascular disease (CVD). Therefore, the medical expenses are higher with the decrease in glomerular filtration rate (GFR). However, few studies have examined the medical expenses according to the baseline GFR. METHODS We investigated the relationship between GFR at health checks and medical expenses, combining the registries of both the health checks and report of medical expenses (receipts). The health checks were done from April 2008 to March 2009, and the eligible subjects were covered by the Okinawa Branch of the Japan Health Insurance Association. All reports of medical expenses were reviewed from April 2008 to March 2010 (24 months). RESULTS A total of 74,354 subjects, 38.2 % females with the mean age of 48.1 years, were examined according to whether they had visited medical facilities during the study period. The total number of receipts was 773,276. The average receipt point, 1 point = 10 Yen, was 686,410 (eGFR < 15), 56,408 (eGFR 15-29), 47,263 (eGFR 30-44), 24,372 (45-59), 16,018 (eGFR 60-74), 13,893 (eGFR 75-89), 13,990 (eGFR 90-104), 14,717 (eGFR 105-119), and 19,139 (eGFR 120 and over), respectively. The relationship between eGFR and medical expense was U-shaped, and the expense was lowest at eGFR 75-89. CONCLUSION We demonstrate that the medical expenses increase as eGFR decreases. Subjects with higher eGFR, 120 and over, seemed to have higher medical expenses.
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Affiliation(s)
- Kunitoshi Iseki
- Dialysis Unit, University Hospital of the Ryukyus, Okinawa, 903-0215, Japan.
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Ritchie J, Green D, Kalra PA. Current views on the management of atherosclerotic renovascular disease. Ann Med 2012; 44 Suppl 1:S98-110. [PMID: 22713155 DOI: 10.3109/07853890.2012.687834] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Atherosclerotic renovascular disease (ARVD) is a common condition in both elderly patients and those with other vascular disease. No published randomized controlled trial has demonstrated an overall benefit of revascularization on any clinical or biochemical end-point, and optimal medical therapy in this condition is not clearly defined. In this review we consider the epidemiology of ARVD and discuss the evidence for current medical treatment. We also address the literature on revascularization, consider settings in which an interventional approach may still be considered, and touch upon on-going areas of research.
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Affiliation(s)
- James Ritchie
- Vascular Research Group, The University of Manchester Academic Health Science Centre, Salford Royal Hospital, Salford, United Kingdom
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38
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Guía de práctica clíníca de la ESC sobre diagnóstico y tratamiento de las enfermedades arteriales periféricas. Rev Esp Cardiol 2012. [DOI: 10.1016/j.recesp.2011.11.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Kondo M, Yamagata K, Hoshi SL, Saito C, Asahi K, Moriyama T, Tsuruya K, Yoshida H, Iseki K, Watanabe T. Cost-effectiveness of chronic kidney disease mass screening test in Japan. Clin Exp Nephrol 2011; 16:279-91. [PMID: 22167460 PMCID: PMC3328680 DOI: 10.1007/s10157-011-0567-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Accepted: 11/11/2011] [Indexed: 12/30/2022]
Abstract
Background Chronic kidney disease (CKD) is a significant public health problem. Strategy for its early detection is still controversial. This study aims to assess the cost-effectiveness of population strategy, i.e. mass screening, and Japan’s health checkup reform. Methods Cost-effectiveness analysis was carried out to compare test modalities in the context of reforming Japan’s mandatory annual health checkup for adults. A decision tree and Markov model with societal perspective were constructed to compare dipstick test to check proteinuria only, serum creatinine (Cr) assay only, or both. Results Incremental cost-effectiveness ratios (ICERs) of mass screening compared with do-nothing were calculated as ¥1,139,399/QALY (US $12,660/QALY) for dipstick test only, ¥8,122,492/QALY (US $90,250/QALY) for serum Cr assay only and ¥8,235,431/QALY (US $91,505/QALY) for both. ICERs associated with the reform were calculated as ¥9,325,663/QALY (US $103,618/QALY) for mandating serum Cr assay in addition to the currently used mandatory dipstick test, and ¥9,001,414/QALY (US $100,016/QALY) for mandating serum Cr assay and applying dipstick test at discretion. Conclusions Taking a threshold to judge cost-effectiveness according to World Health Organization’s recommendation, i.e. three times gross domestic product per capita of ¥11.5 million/QALY (US $128 thousand/QALY), a policy that mandates serum Cr assay is cost-effective. The choice of continuing the current policy which mandates dipstick test only is also cost-effective. Our results suggest that a population strategy for CKD detection such as mass screening using dipstick test and/or serum Cr assay can be justified as an efficient use of health care resources in a population with high prevalence of the disease such as in Japan and Asian countries.
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Affiliation(s)
- Masahide Kondo
- Department of Health Care Policy and Management, Graduate School of Comprehensive Sciences, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8577, Japan.
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Risk factor profile for chronic kidney disease is similar to risk factor profile for small artery disease. J Hypertens 2011; 29:1796-801. [PMID: 21720267 DOI: 10.1097/hjh.0b013e328349052b] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND METHOD We investigated whether chronic kidney disease detected by increased serum creatinine (S(Cr)) or urine albumin-to-creatinine ratio (U(ACR)) may reflect arteriosclerosis involving the kidneys. The sample consisted of 1585 members of sibships (804 non-Hispanic whites and 781 non-Hispanic blacks) in which at least two siblings had primary hypertension. We first evaluated the correlations of increased S(Cr) and U(ACR) with the presence of cerebral small vessel arteriosclerosis, which was determined by increased subcortical white matter hyperintensity (WMH) volume on brain magnetic resonance imaging; and with peripheral large vessel arteriosclerosis, which was determined by decreased ankle-brachial index (ABI). After age adjustment, increased S(Cr) and U(ACR) correlated with increased WMH volume (0.54 and 0.52, respectively) and with decreased ABI (0.50 and 0.54, respectively; all P < 0.001). We then used logistic regression to evaluate the dependency of each measure of disease on conventional risk factors for arteriosclerosis to assess whether the risk factors' effects were proportional across different measures of disease. RESULTS Age, race, sex, hypertension, diabetes, total cholesterol, and smoking made similar overall contributions to the prediction of each measure of disease, as judged by the model C-statistics, which varied in a narrow range from 0.84 to 0.85 (all P < 0.001). However, the relative contributions that the modifiable risk factors, including hypertension, diabetes, total cholesterol, and smoking made to prediction of increased S(Cr) and U(ACR) were disproportionate to their relative contributions to prediction of decreased ABI (P < 0.0001). CONCLUSION The findings support the view that chronic kidney disease detected by increased S(Cr) or U(ACR) primarily reflects small vessel arteriosclerosis involving the kidneys.
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Abstract
Hypertension is a common systemic disorder affecting the cardiovascular system and kidneys with important morbidity and mortality. However, hypertension is often thought of by radiologists as an "invisible" disease. The aim of this article is to first review hypertension first in terms of its diagnosis, epidemiology and clinical importance. Second, those causes of secondary hypertension that may be diagnosed with MRI techniques are described along with the effects of hypertension on the cardiovascular system and kidneys that are demonstrable with MRI with particular emphasis on renovascular disease. Lastly the use of integrated MRI protocols to evaluate the hypertensive patient and areas for future research are considered.
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Affiliation(s)
- Giles Roditi
- Department of Radiology, Glasgow Royal Infirmary, Glasgow, Scotland, United Kingdom.
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Hegde U, Rajapurkar M, Gang S, Khanapet M, Durugkar S, Gohel K, Aghor N, Ganju A, Dabhi M. Fifteen Years’ Experience of Treating Atherosclerotic Renal Artery Stenosis by Interventional Nephrologists in India. Semin Dial 2011; 25:97-104. [DOI: 10.1111/j.1525-139x.2011.00962.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Weinberg I, Jaff MR. Controversies surrounding renal artery intervention: making sense of the confusion. Interv Cardiol 2011. [DOI: 10.2217/ica.11.60] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Tendera M, Aboyans V, Bartelink ML, Baumgartner I, Clément D, Collet JP, Cremonesi A, De Carlo M, Erbel R, Fowkes FGR, Heras M, Kownator S, Minar E, Ostergren J, Poldermans D, Riambau V, Roffi M, Röther J, Sievert H, van Sambeek M, Zeller T. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J 2011; 32:2851-906. [PMID: 21873417 DOI: 10.1093/eurheartj/ehr211] [Citation(s) in RCA: 1044] [Impact Index Per Article: 80.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
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- 3rd Division of Cardiology, Medical University of Silesia, Ziolowa 47, 40-635 Katowice, Poland.
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Messerli FH, Bangalore S, Makani H, Rimoldi SF, Allemann Y, White CJ, Textor S, Sleight P. Flash pulmonary oedema and bilateral renal artery stenosis: the Pickering Syndrome. Eur Heart J 2011; 32:2231-5. [PMID: 21406441 DOI: 10.1093/eurheartj/ehr056] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Franz H Messerli
- Division of Cardiovascular Medicine, St Luke's and Roosevelt Hospitals, Columbia University College of Physicians and Surgeons, 1000 Tenth Avenue, New York, NY 10019, USA.
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Chade AR. Renovascular disease, microcirculation, and the progression of renal injury: role of angiogenesis. Am J Physiol Regul Integr Comp Physiol 2011; 300:R783-90. [PMID: 21307362 DOI: 10.1152/ajpregu.00657.2010] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Emerging evidence supports the pivotal role of renal microvascular disease as a determinant of tubulo-interstitial and glomerular fibrosis in chronic kidney disease. An intact microcirculation is vital to restore blood flow to the injured tissues, which is a crucial step to achieve a successful repair response. The purpose of this review is to discuss the impact and mechanisms of the functional and structural changes of the renal microvascular network, as well as the role of these changes in the progression and irreversibility of renal injury. Damage of the renal microcirculation and deterioration of the angiogenic response may constitute early steps in the complex pathways involved in progressive renal injury. There is limited but provocative evidence that stimulation of vascular proliferation and repair may stabilize renal function and slow the progression of renal disease. The feasibility of novel potential therapeutic interventions for stabilizing the renal microvasculature is also discussed. Targeted interventions to enhance endogenous renoprotective mechanisms focused on the microcirculation, such as cell-based therapy or the use of angiogenic cytokines have shown promising results in some experimental and clinical settings.
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Affiliation(s)
- Alejandro R Chade
- Department of Physiology and Biophysics, Center for Excellence in Cardiovascular-Renal Research, and University of Mississippi Medical Center, Jackson, Mississippi 39216-4505, USA.
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Eriksson P, Mohammed AA, De Geer J, Kihlberg J, Persson A, Granerus G, Nystrom F, Smedby O. Non-invasive investigations of potential renal artery stenosis in renal insufficiency. Nephrol Dial Transplant 2010; 25:3607-14. [DOI: 10.1093/ndt/gfq259] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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