1
|
Kang IS, Choi D, Ko YG, Shin DH, Kim JS, Kim BK, Hong MK, Jang Y. Long-term outcomes of percutaneous transluminal renal artery intervention: a retrospective study at a single center. Clin Hypertens 2024; 30:21. [PMID: 39085980 PMCID: PMC11293128 DOI: 10.1186/s40885-024-00282-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 06/26/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND The indications, benefits, and outcomes of percutaneous transluminal renal artery intervention (PTRI) remain controversial. The study purpose was to evaluate the long-term outcomes of PTRI in clinical practice. METHODS A retrospective review of 217 subjects (254 renal arteries; mean age, 59.8 years) who underwent PTRI based on medical database. RESULTS The most common cause of renal artery stenosis was atherosclerosis in 217 (85.4%), followed by Takayasu arteritis (TA) in 23 (9.1%), fibromuscular dysplasia in five (2.0%) and others in nine (3.5%). Mean follow-up duration was 5.7 ± 3.7 years. The first restenosis rate was 7.5% (n = 19; highest in TA: n = 9, 47.4%) and second restenosis occurred in six arteries (five TAs, one fibromuscular dysplasia). Follow-up blood pressure improved from 142.0/83.5 to 122.8/73.5 mmHg (P < 0.001). There was no change within 5 years' follow-up in estimated glomerular filtration rate (P = 0.44), whereas TA changed from 69.8 ± 20.5 to 84.2 ± 17.9 mL/min/1.73 m² (P = 0.008). Progressive renal dysfunction was related to diabetes mellitus, chronic kidney disease, and peripheral artery obstructive disease on multivariate analysis with hazard ratios (95% confidence intervals) of 2.24 (1.21-4.17), 2.54 (1.33-4.84), and 3.93 (1.97-7.82), respectively. CONCLUSIONS PTRI was associated with a blood pressure reduction. Despite a higher rate of restenosis, patients with TA showed significant improvement in estimated glomerular filtration rate. Diabetes mellitus, chronic kidney disease, and peripheral artery obstructive disease were related with progressive renal dysfunction after PTRI.
Collapse
Affiliation(s)
- In Sook Kang
- Division of Cardiology, Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Donghoon Choi
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Young-Guk Ko
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong-Ho Shin
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung-Sun Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byeong-Keuk Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Myeong-Ki Hong
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yangsoo Jang
- Division of Cardiology, Department of Internal Medicine, CHA Gangnam Medical Center, CHA University, Seongnam, Republic of Korea
| |
Collapse
|
2
|
Drieghe B, De Buyzere M, Bové T, De Backer T. Interventions for renal artery stenosis: Appraisal of novel physiological insights and procedural techniques to improve clinical outcome. Catheter Cardiovasc Interv 2024; 104:285-299. [PMID: 38837309 DOI: 10.1002/ccd.31117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 05/07/2024] [Accepted: 05/25/2024] [Indexed: 06/07/2024]
Abstract
Randomized clinical trials failed to show additional benefit of renal artery stenting on top of medical therapy. Instead of writing an obituary on renal artery stenting, we try to explain these disappointing results. A transstenotic pressure gradient is needed to reduce renal perfusion and to activate the renin-angiotensin-aldosterone system. In only a minority of patients included in trials, a transstenotic pressure gradient is measured and reported. Like the coronary circulation, integration of physiological lesion assessment will allow to avoid stenting of non-significant lesions and select those patients that are most likely to benefit from renal artery stenting. Renal artery interventions are associated with peri-procedural complications. Contemporary techniques, including radial artery access, no-touch technique to engage the renal ostium and the use of embolic protection devices, will minimize procedural risk. Combining optimal patient selection and meticulous technique might lead to a netto clinical benefit when renal artery stenting is added to optimal medical therapy.
Collapse
Affiliation(s)
- Benny Drieghe
- Heart Center, University Hospital Gent, Gent, Belgium
| | | | - Thierry Bové
- Heart Center, University Hospital Gent, Gent, Belgium
| | | |
Collapse
|
3
|
Zhu XY, Klomjit N, Pawar AS, Puranik AS, Yang ZZ, Lutgens E, Eirin A, Lerman A, Textor SC, Lerman LO. Altered immune cell phenotypes within chronically ischemic human kidneys distal to occlusive renal artery disease. Am J Physiol Renal Physiol 2024; 326:F257-F264. [PMID: 38031731 PMCID: PMC11198973 DOI: 10.1152/ajprenal.00234.2023] [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] [Received: 08/08/2023] [Revised: 10/04/2023] [Accepted: 11/22/2023] [Indexed: 12/01/2023] Open
Abstract
Renal artery stenosis (RAS) is a major cause of ischemic kidney disease, which is largely mediated by inflammation. Mapping the immune cell composition in ischemic kidneys might provide useful insight into the disease pathogenesis and uncover therapeutic targets. We used mass cytometry (CyTOF) to explore the single-cell composition in a unique data set of human kidneys nephrectomized due to chronic occlusive vascular disease (RAS, n = 3), relatively healthy donor kidneys (n = 6), and unaffected sections of kidneys with renal cell carcinoma (RCC, n = 3). Renal fibrosis and certain macrophage populations were also evaluated in renal sections. Cytobank analysis showed in RAS kidneys decreased cell populations expressing epithelial markers (CD45-/CD13+) and increased CD45+ inflammatory cells, whereas scattered tubular-progenitor-like cells (CD45-/CD133+/CD24+) increased compared with kidney donors. Macrophages switched to proinflammatory phenotypes in RAS, and the numbers of IL-10-producing dendritic cells (DC) were also lower. Compared with kidney donors, RAS kidneys had decreased overall DC populations but increased plasmacytoid DC. Furthermore, senescent active T cells (CD45+/CD28+/CD57+), aged neutrophils (CD45+/CD15+/CD24+/CD11c+), and regulatory B cells (CD45+/CD14-/CD24+/CD44+) were increased in RAS. RCC kidneys showed a distribution of cell phenotypes comparable with RAS but less pronounced, accompanied by an increase in CD34+, CD370+, CD103+, and CD11c+/CD103+ cells. Histologically, RAS kidneys showed significantly increased fibrosis and decreased CD163+/CD141+ cells. The single-cell platform CyTOF enables the detection of significant changes in renal cells, especially in subsets of immune cells in ischemic human kidneys. Endogenous pro-repair cell types in RAS warrant future study for potential immune therapy.NEW & NOTEWORTHY The single-cell platform mass cytometry (CyTOF) enables detection of significant changes in one million of renal cells, especially in subsets of immune cells in ischemic human kidneys distal to renal artery stenosis (RAS). We found that pro-repair cell types such as scattered tubular-progenitor-like cells, aged neutrophils, and regulatory B cells show a compensatory increase in RAS. Immune cell phenotype changes may reflect ongoing inflammation and impaired immune defense capability in the kidneys.
Collapse
Affiliation(s)
- Xiang-Yang Zhu
- Division of Nephrology & Hypertension, Mayo Clinic, Rochester, Minnesota, United States
| | - Nattawat Klomjit
- Division of Nephrology & Hypertension, Mayo Clinic, Rochester, Minnesota, United States
| | - Aditya S Pawar
- Division of Nephrology & Hypertension, Mayo Clinic, Rochester, Minnesota, United States
| | - Amrutesh S Puranik
- Division of Nephrology & Hypertension, Mayo Clinic, Rochester, Minnesota, United States
| | - Zhi-Zhang Yang
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, United States
| | - Esther Lutgens
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States
| | - Alfonso Eirin
- Division of Nephrology & Hypertension, Mayo Clinic, Rochester, Minnesota, United States
| | - Amir Lerman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States
| | - Stephen C Textor
- Division of Nephrology & Hypertension, Mayo Clinic, Rochester, Minnesota, United States
| | - Lilach O Lerman
- Division of Nephrology & Hypertension, Mayo Clinic, Rochester, Minnesota, United States
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States
| |
Collapse
|
4
|
Drieghe B, van Loon G, Decloedt A, Stuyvaert S, De Buyzere ML, Bové T, De Backer T. Defining Hemodynamic Significance of Renal Artery Stenosis: Insights From a Porcine Model of Graded Renal Artery Stenosis. Acad Radiol 2023; 30 Suppl 1:S286-S294. [PMID: 37120404 DOI: 10.1016/j.acra.2023.03.033] [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: 12/04/2022] [Revised: 03/20/2023] [Accepted: 03/23/2023] [Indexed: 05/01/2023]
Abstract
RATIONALE AND OBJECTIVES To investigate the renal pressure-flow relationship and its relation to renin release, because the renal perfusion pressure below which renal flow starts to decline and renin secretion is upregulated is unclear. MATERIALS AND METHODS A porcine model of graded unilateral renal artery stenosis was created. The severity of the stenosis was expressed as the ratio between distal renal pressure (Pd) and aortic pressure (Pa). Pd and renal flow velocity were continuously measured using a combined pressure-flow wire (Combowire®). Hemodynamic measurements and blood sampling for renin, angiotensin and aldosterone were performed in baseline conditions and during progressive balloon inflation in the renal artery leading to Pd decrease per 5% increment. Resistive index (RI) was computed as (1 - (End Diastolic V/Peak Systolic V))*100. RESULTS For a 5% decrease in renal perfusion pressure (95% of aortic pressure or 5% decrease compared to Pa), peak systolic velocity started to decrease. A significant decrease in average peak flow velocity was observed when distal renal perfusion pressure decreased by 25% and was associated with activation of ipsilateral renin secretion. The RI decreased already for minimal changes in Pd/Pa ratio. CONCLUSION In an animal model of unilateral graded renal artery stenosis, a 25% decrease in perfusion pressure results in a significant decrease in distal renal flow, causing upregulation of renin secretion.
Collapse
Affiliation(s)
- Benny Drieghe
- Heart Center, University Hospital Ghent, Belgium (B.D., M.L.D.B., T.B., T.D.B.).
| | - Gunther van Loon
- Dept of Internal Medicine, Reproduction and Population Medicine, Faculty of Veterinary Medicine, Ghent University, Belgium (G.V.L., A.D., S.S.).
| | - Annelies Decloedt
- Dept of Internal Medicine, Reproduction and Population Medicine, Faculty of Veterinary Medicine, Ghent University, Belgium (G.V.L., A.D., S.S.).
| | - Sabrina Stuyvaert
- Dept of Internal Medicine, Reproduction and Population Medicine, Faculty of Veterinary Medicine, Ghent University, Belgium (G.V.L., A.D., S.S.).
| | - Marc L De Buyzere
- Heart Center, University Hospital Ghent, Belgium (B.D., M.L.D.B., T.B., T.D.B.).
| | - Thierry Bové
- Heart Center, University Hospital Ghent, Belgium (B.D., M.L.D.B., T.B., T.D.B.).
| | - Tine De Backer
- Heart Center, University Hospital Ghent, Belgium (B.D., M.L.D.B., T.B., T.D.B.).
| |
Collapse
|
5
|
Zhao Y, Shi Y, Jin Y, Cao Y, Song H, Chen L, Li F, Li X, Chen W. Evaluating Short-Term and Long-Term Risks Associated with Renal Artery Stenosis Position and Severity: A Hemodynamic Study. Bioengineering (Basel) 2023; 10:1002. [PMID: 37760104 PMCID: PMC10525140 DOI: 10.3390/bioengineering10091002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/16/2023] [Accepted: 08/21/2023] [Indexed: 09/29/2023] Open
Abstract
Background: Moderate renal artery stenosis (50-70%) may lead to uncontrolled hypertension and eventually cause irreversible damage to renal function. However, the clinical criteria for interventional treatment are still ambiguous in this condition. This study investigated the impact of the position and degree of renal artery stenosis on hemodynamics near the renal artery to assess the short-term and long-term risks associated with this disease. Methods: Calculation models with different degrees of stenosis (50%, 60%, and 70%) located at different positions in the right renal artery were established based on the computed tomography angiography (CTA) of a personalized case. And computational fluid dynamics (CFD) was used to analyze hemodynamic surroundings near the renal artery. Results: As the degree of stenosis increases and the stenosis position is far away from the aorta, there is a decrease in renal perfusion. An analysis of the wall shear stress (WSS)-related parameters indicated areas near the renal artery (downstream of the stenosis and the entrance of the right renal artery) with potential long-term risks of thrombosis and inflammation. Conclusion: The position and degree of stenosis play a significant role in judging short-term risks associated with renal perfusion. Moreover, clinicians should consider not only short-term risks but also independent long-term risk factors, such as certain regions of 50% stenosis with adequate renal perfusion may necessitate prompt intervention.
Collapse
Affiliation(s)
- Yawei Zhao
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan 030024, China; (Y.Z.); (Y.S.); (Y.J.); (Y.C.); (X.L.); (W.C.)
| | - Yike Shi
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan 030024, China; (Y.Z.); (Y.S.); (Y.J.); (Y.C.); (X.L.); (W.C.)
| | - Yusheng Jin
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan 030024, China; (Y.Z.); (Y.S.); (Y.J.); (Y.C.); (X.L.); (W.C.)
| | - Yifan Cao
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan 030024, China; (Y.Z.); (Y.S.); (Y.J.); (Y.C.); (X.L.); (W.C.)
| | - Hui Song
- College of Mechanical and Vehicle Engineering, Taiyuan University of Technology, Taiyuan 030024, China;
- Institute of Applied Mechanics, Taiyuan University of Technology, Taiyuan 030024, China
| | - Lingfeng Chen
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan 030024, China; (Y.Z.); (Y.S.); (Y.J.); (Y.C.); (X.L.); (W.C.)
| | - Fen Li
- College of Mechanical and Vehicle Engineering, Taiyuan University of Technology, Taiyuan 030024, China;
- Institute of Applied Mechanics, Taiyuan University of Technology, Taiyuan 030024, China
| | - Xiaona Li
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan 030024, China; (Y.Z.); (Y.S.); (Y.J.); (Y.C.); (X.L.); (W.C.)
| | - Weiyi Chen
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan 030024, China; (Y.Z.); (Y.S.); (Y.J.); (Y.C.); (X.L.); (W.C.)
| |
Collapse
|
6
|
Galley JC, Hahn SA, Miller MP, Durgin BG, Jackson EK, Stocker SD, Straub AC. Angiotensin II augments renal vascular smooth muscle soluble GC expression via an AT 1 receptor-forkhead box subclass O transcription factor signalling axis. Br J Pharmacol 2022; 179:2490-2504. [PMID: 33963547 PMCID: PMC8883839 DOI: 10.1111/bph.15522] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/18/2021] [Accepted: 04/23/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Reduced renal blood flow triggers activation of the renin-angiotensin-aldosterone system (RAAS) leading to renovascular hypertension. Renal vascular smooth muscle expression of the NO receptor, soluble GC (sGC), modulates the vasodilator response needed to control renal vascular tone and blood flow. Here, we tested if angiotensin II (Ang II) affects sGC expression via an AT1 receptor-forkhead box subclass O (FoxO) transcription factor dependent mechanism. EXPERIMENTAL APPROACH Using a murine two-kidney-one-clip (2K1C) renovascular hypertension model, we measured renal artery vasodilatory function and sGC expression. Additionally, we conducted cell culture studies using rat renal pre-glomerular smooth muscle cells (RPGSMCs) to test the in vitro mechanistic effects of Ang II treatment on sGC expression and downstream function. KEY RESULTS Contralateral, unclipped renal arteries in 2K1C mice showed increased NO-dependent vasorelaxation compared to sham control mice. Immunofluorescence studies revealed increased sGC protein expression in 2K1C contralateral renal arteries over sham controls. RPGSMCs treated with Ang II caused a significant up-regulation of sGC mRNA and protein expression as well as downstream sGC-dependent signalling. Ang II signalling effects on sGC expression occurred through an AT1 receptor and FoxO transcription factor-dependent mechanism at both the mRNA and protein expression levels. CONCLUSION AND IMPLICATIONS Renal artery smooth muscle, in vivo and in vitro, up-regulates expression of sGC following RAAS activity. In both cases, up-regulation of sGC leads to increased downstream cGMP signalling, suggesting a previously unrecognized protective mechanism to improve renal blood flow in the uninjured contralateral renal artery. LINKED ARTICLES This article is part of a themed issue on cGMP Signalling in Cell Growth and Survival. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v179.11/issuetoc.
Collapse
Affiliation(s)
- Joseph C. Galley
- Heart, Lung, Blood and Vascular Medicine Institute,
University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pharmacology and Chemical Biology, University
of Pittsburgh, Pittsburgh, Pennsylvania
| | - Scott A. Hahn
- Heart, Lung, Blood and Vascular Medicine Institute,
University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Megan P. Miller
- Heart, Lung, Blood and Vascular Medicine Institute,
University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Brittany G. Durgin
- Heart, Lung, Blood and Vascular Medicine Institute,
University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Edwin K. Jackson
- Department of Pharmacology and Chemical Biology, University
of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sean D. Stocker
- Department of Medicine, Renal-Electrolyte Division,
University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Adam C. Straub
- Heart, Lung, Blood and Vascular Medicine Institute,
University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pharmacology and Chemical Biology, University
of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
7
|
Funes Hernandez M, Bhalla V, Isom RT. Hypothesis: Accessory renal arteries may be an overlooked cause of renin-dependent hypertension. J Hum Hypertens 2022; 36:493-497. [PMID: 34785773 DOI: 10.1038/s41371-021-00632-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 09/14/2021] [Accepted: 10/26/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Mario Funes Hernandez
- Stanford Hypertension Center, Stanford University School of Medicine, Stanford, CA, USA.,Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Vivek Bhalla
- Stanford Hypertension Center, Stanford University School of Medicine, Stanford, CA, USA.,Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Robert T Isom
- Stanford Hypertension Center, Stanford University School of Medicine, Stanford, CA, USA. .,Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| |
Collapse
|
8
|
Lucera GM, Menani JV, Colombari E, Colombari DSA. ANG II and Aldosterone Acting Centrally Participate in the Enhanced Sodium Intake in Water-Deprived Renovascular Hypertensive Rats. Front Pharmacol 2021; 12:679985. [PMID: 34113255 PMCID: PMC8186501 DOI: 10.3389/fphar.2021.679985] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/04/2021] [Indexed: 11/29/2022] Open
Abstract
Renovascular hypertension is a type of secondary hypertension caused by renal artery stenosis, leading to an increase in the renin–angiotensin–aldosterone system (RAAS). Two-kidney, 1-clip (2K1C) is a model of renovascular hypertension in which rats have an increased sodium intake induced by water deprivation (WD), a common situation found in the nature. In addition, a high-sodium diet in 2K1C rats induces glomerular lesion. Therefore, the purpose of this study was to investigate whether angiotensin II (ANG II) and/or aldosterone participates in the increased sodium intake in 2K1C rats under WD. In addition, we also verified if central AT1 and mineralocorticoid receptor blockade would change the high levels of arterial pressure in water-replete (WR) and WD 2K1C rats, because blood pressure changes can facilitate or inhibit water and sodium intake. Finally, possible central areas activated during WD or WD followed by partial rehydration (PR) in 2K1C rats were also investigated. Male Holtzman rats (150–180 g) received a silver clip around the left renal artery to induce renovascular hypertension. Six weeks after renal surgery, a stainless-steel cannula was implanted in the lateral ventricle, followed by 5–7 days of recovery before starting tests. Losartan (AT1 receptor antagonist) injected intracerebroventricularly attenuated water intake during the thirst test. Either icv losartan or RU28318 (mineralocorticoid receptor antagonist) reduced 0.3 M NaCl intake, whereas the combination of losartan and RU28318 icv totally blocked 0.3 M NaCl intake induced by WD in 2K1C rats. Losartan and RU28318 icv did not change hypertension levels of normohydrated 2K1C rats, but reduced the increase in mean arterial pressure (MAP) produced by WD. c-Fos expression increased in the lamina terminalis and in the NTS in WD condition, and increased even more after WD-PR. These results suggest the participation of ANG II and aldosterone acting centrally in the enhanced sodium intake in WD 2K1C rats, and not in the maintenance of hypertension in satiated and fluid-replete 2K1C rats.
Collapse
Affiliation(s)
- Gabriela Maria Lucera
- Department of Physiology and Pathology, School of Dentistry, Sao Paulo State University, Araraquara, Brazil
| | - José Vanderlei Menani
- Department of Physiology and Pathology, School of Dentistry, Sao Paulo State University, Araraquara, Brazil
| | - Eduardo Colombari
- Department of Physiology and Pathology, School of Dentistry, Sao Paulo State University, Araraquara, Brazil
| | | |
Collapse
|
9
|
Wang L, Zhu L, Li G, Zhang Y, Jiang Y, Shui B, Zhang X. Gadolinium-enhanced magnetic resonance versus computed tomography angiography for renal artery stenosis: A systematic review and meta-analysis. J Formos Med Assoc 2021; 120:1171-1178. [PMID: 33583703 DOI: 10.1016/j.jfma.2021.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/24/2020] [Accepted: 01/06/2021] [Indexed: 10/22/2022] Open
Abstract
Gadolinium-enhanced magnetic resonance angiography (MRA) and computed tomography angiography (CTA) are commonly used for diagnosing renal arterial stenosis (RAS); however, the diagnostic value is yet controversial. The aim of the study was to evaluate the diagnostic values of both methods. Electronic databases, including PubMed, Embase, and the Cochrane Library, were searched for studies, since inception until October 2017. A total of four articles involving 486 subjects were included in the analysis. The summary of sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the receiver operating characteristic (ROC) (AUC) were 0.70, 0.82, 14.54, 0.29, 63.80, and 0.81 for MRA-based diagnosis of RAS, respectively. The pooled sensitivity, specificity, PLR, NLR, DOR, and AUC for CTA detecting RAS were 0.73, 0.96, 13.04, 0.29, 71.99, and 0.93, respectively. Gadolinium-enhanced MRA and CTA provide a satisfactory diagnostic accuracy, thereby playing a critical role in the diagnosis of RAS.
Collapse
Affiliation(s)
- Lisha Wang
- Radiology Department, Xiangyang NO.1 Hospital, The Affiliated Hospital of Hubei University of Medicine, Xiangyang, 441000, China
| | - Lei Zhu
- Cardiovascular Medicine Department, Xiangyang NO.1 Hospital, The Affiliated Hospital of Hubei University of Medicine, Xiangyang, 441000, China.
| | - Guang Li
- Xiangyang Ping an Healthcare Medical Imaging Co, Ltd, Xiangyang, 441000, China
| | - Yue Zhang
- Radiology Department, Xiangyang NO.1 Hospital, The Affiliated Hospital of Hubei University of Medicine, Xiangyang, 441000, China
| | - Yunyun Jiang
- Radiology Department, Xiangyang NO.1 Hospital, The Affiliated Hospital of Hubei University of Medicine, Xiangyang, 441000, China
| | - Bo Shui
- Radiology Department, Xiangyang NO.1 Hospital, The Affiliated Hospital of Hubei University of Medicine, Xiangyang, 441000, China
| | - Xian Zhang
- Radiology Department, Xiangyang NO.1 Hospital, The Affiliated Hospital of Hubei University of Medicine, Xiangyang, 441000, China
| |
Collapse
|
10
|
Ameenuddin M, Anand M. A Mixture Theory Model for Blood Combined With Low-Density Lipoprotein Transport to Predict Early Atherosclerosis Regions in Idealized and Patient-Derived Abdominal Aorta. J Biomech Eng 2020; 142:101008. [PMID: 32507886 DOI: 10.1115/1.4047426] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Indexed: 07/25/2024]
Abstract
Genesis and onset of atherosclerosis are greatly influenced by hemodynamic forces. Two-phase transient computational fluid dynamic (CFD) simulations are performed using a mixture theory model for blood, and a transport equation for low-density lipoprotein (LDL), in idealized and patient-derived abdominal aorta to predict the sites at risk for atherosclerosis. Flow patterns at different time instants and relevant hemodynamic indicators-wall shear stress (WSS)-based (time-averaged wall shear stress (TAWSS), oscillatory shear index (OSI), and relative residence time (RRT)), and LDL concentration-are used concurrently to predict the susceptible sites of atherosclerosis. In the case of idealized geometry, flow recirculations are observed on the posterior wall opposite the superior mesenteric artery and below the renal bifurcations. Low TAWSS, high OSI, high RRT and high concentration of LDL are observed in these regions. This suggests that in idealized abdominal aorta, the posterior wall proximal to the renal artery junction is more prone to atherosclerosis. This matches qualitatively with the experimental and simulation data in the literature. In the case of patient-derived geometry, flow reversal, low TAWSS, high OSI and high RRT are observed infrarenal on the anterior wall. Further, high concentration of LDL is observed at the same location on the anterior wall suggesting anterior wall distal to the renal artery junction is more prone to atherosclerosis. These findings demonstrate the use of a novel method to predict the sites at risk for atherosclerosis in geometries where complexities like junctions and curvature play a major role.
Collapse
Affiliation(s)
- Mohammed Ameenuddin
- Department of Chemical Engineering, Indian Institute of Technology Hyderabad, Sangareddy, Telangana 502285, India
| | - Mohan Anand
- Department of Chemical Engineering, Indian Institute of Technology Hyderabad, Sangareddy, Telangana 502285, India
| |
Collapse
|
11
|
Higashitani T, Karashima S, Aono D, Konishi S, Kometani M, Oka R, Demura M, Furukawa K, Yamazaki Y, Sasano H, Yoneda T, Takeda Y. A case of renovascular hypertension with incidental primary bilateral macronodular adrenocortical hyperplasia. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM190163. [PMID: 33434182 PMCID: PMC7424347 DOI: 10.1530/edm-19-0163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 06/15/2020] [Indexed: 11/08/2022] Open
Abstract
SUMMARY Renovascular hypertension (RVHT) is an important and potentially treatable form of resistant hypertension. Hypercortisolemia could also cause hypertension and diabetes mellitus. We experienced a case wherein adrenalectomy markedly improved blood pressure and plasma glucose levels in a patient with RVHT and low-level autonomous cortisol secretion. A 62-year-old Japanese man had been treated for hypertension and diabetes mellitus for 10 years. He was hospitalized because of a disturbance in consciousness. His blood pressure (BP) was 236/118 mmHg, pulse rate was 132 beats/min, and plasma glucose level was 712 mg/dL. Abdominal CT scanning revealed the presence of bilateral adrenal masses and left atrophic kidney. Abdominal magnetic resonance angiography demonstrated marked stenosis of the left main renal artery. The patient was subsequently diagnosed with atherosclerotic RVHT with left renal artery stenosis. His left adrenal lobular mass was over 40 mm and it was clinically suspected the potential for cortisol overproduction. Therefore, laparoscopic left nephrectomy and adrenalectomy were simultaneously performed, resulting in improved BP and glucose levels. Pathological studies revealed the presence of multiple cortisol-producing adrenal nodules and aldosterone-producing cell clusters in the adjacent left adrenal cortex. In the present case, the activated renin-angiotensin-aldosterone system and cortisol overproduction resulted in severe hypertension, which was managed with simultaneous unilateral nephrectomy and adrenalectomy. LEARNING POINTS Concomitant activation of the renin-angiotensin-aldosterone system and cortisol overproduction may contribute to the development of severe hypertension and lead to lethal cardiovascular complications. Treatment with simultaneous unilateral nephrectomy and adrenalectomy markedly improves BP and blood glucose levels. CYP11B2 immunohistochemistry staining revealed the existence of aldosterone-producing cell clusters (APCCs) in the adjacent non-nodular adrenal gland, suggesting that APCCs may contribute to aldosterone overproduction in patients with RVHT.
Collapse
Affiliation(s)
- Takuya Higashitani
- Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Shigehiro Karashima
- Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Daisuke Aono
- Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Seigoh Konishi
- Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
- Department of Internal Medicine, Keiju Medical Center, Nanao, Ishikawa, Japan
| | - Mitsuhiro Kometani
- Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Rie Oka
- Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Masashi Demura
- Department of Hygiene, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Kenji Furukawa
- Health Care Center, Japan Advanced Institute of Science and Technology, Nomi, Ishikawa, Japan
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Takashi Yoneda
- Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
- Department of Health Promotion and Medicine of the Future, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Yoshiyu Takeda
- Division of Endocrinology and Hypertension, Department of Cardiovascular and Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| |
Collapse
|
12
|
Zhang S, Breidenbach JD, Khalaf FK, Dube PR, Mohammed CJ, Lad A, Stepkowski S, Hinds TD, Kumarasamy S, Kleinhenz A, Tian J, Malhotra D, Kennedy DJ, Cooper CJ, Haller ST. Renal Fibrosis Is Significantly Attenuated Following Targeted Disruption of Cd40 in Experimental Renal Ischemia. J Am Heart Assoc 2020; 9:e014072. [PMID: 32200719 PMCID: PMC7428653 DOI: 10.1161/jaha.119.014072] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Renal artery stenosis is a common cause of renal ischemia, contributing to the development of chronic kidney disease. To investigate the role of local CD40 expression in renal artery stenosis, Goldblatt 2‐kidney 1‐clip surgery was performed on hypertensive Dahl salt‐sensitive rats (S rats) and genetically modified S rats in which CD40 function is abolished (Cd40mutant). Methods and Results Four weeks following the 2‐kidney 1‐clip procedure, Cd40mutant rats demonstrated significantly reduced blood pressure and renal fibrosis in the ischemic kidneys compared with S rat controls. Similarly, disruption of Cd40 resulted in reduced 24‐hour urinary protein excretion in Cd40mutant rats versus S rat controls (46.2±1.9 versus 118.4±5.3 mg/24 h; P<0.01), as well as protection from oxidative stress, as indicated by increased paraoxonase activity in Cd40mutant rats versus S rat controls (P<0.01). Ischemic kidneys from Cd40mutant rats demonstrated a significant decrease in gene expression of the profibrotic mediator, plasminogen activator inhibitor‐1 (P<0.05), and the proinflammatory mediators, C‐C motif chemokine ligand 19 (P<0.01), C‐X‐C Motif Chemokine Ligand 9 (P<0.01), and interleukin‐6 receptor (P<0.001), compared with S rat ischemic kidneys, as assessed by quantitative PCR assay. Reciprocal renal transplantation documented that CD40 exclusively expressed in the kidney contributes to ischemia‐induced renal fibrosis. Furthermore, human CD40‐knockout proximal tubule epithelial cells suggested that suppression of CD40 signaling significantly inhibited expression of proinflammatory and ‐fibrotic genes. Conclusions Taken together, our data suggest that activation of CD40 induces a significant proinflammatory and ‐fibrotic response and represents an attractive therapeutic target for treatment of ischemic renal disease.
Collapse
Affiliation(s)
- Shungang Zhang
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Joshua D. Breidenbach
- Department of Medical Microbiology and ImmunologyUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Fatimah K. Khalaf
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Prabhatchandra R. Dube
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Chrysan J. Mohammed
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Apurva Lad
- Department of Medical Microbiology and ImmunologyUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Stanislaw Stepkowski
- Department of Medical Microbiology and ImmunologyUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Terry D. Hinds
- Department of Physiology and PharmacologyUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Sivarajan Kumarasamy
- Department of Physiology and PharmacologyUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Andrew Kleinhenz
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Jiang Tian
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Deepak Malhotra
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - David J. Kennedy
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Christopher J. Cooper
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Steven T. Haller
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| |
Collapse
|
13
|
Hannah-Shmouni F, Gubbi S, Spence JD, Stratakis CA, Koch CA. Resistant Hypertension: A Clinical Perspective. Endocrinol Metab Clin North Am 2019; 48:811-828. [PMID: 31655778 DOI: 10.1016/j.ecl.2019.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Resistant hypertension is a common clinical entity, defined as suboptimal blood pressure response to multiple therapies after excluding medication nonadherence and secondary forms of hypertension. Patients with resistant hypertension generally share several comorbidities. Resistant hypertension is more common in individuals of African descent. Blood pressure should be optimized using multiple strategies, including lifestyle changes and single-pill combination therapies, with the aim of reducing cardiovascular events while reducing side effects from using antihypertensive therapy. A renin/aldosterone-based diagnostic and treatment approach will help tailor therapy. The use of mineralocorticoid receptor antagonists or amiloride as appropriate is favored.
Collapse
Affiliation(s)
- Fady Hannah-Shmouni
- Internal Medicine-Endocrinology, Hypertension and Metabolic Genetics, Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 10 Center Drive, MSC 1109, Bethesda, MD 20892, USA.
| | - Sriram Gubbi
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney diseases, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892, USA
| | - J David Spence
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, 1400 Western Road, London, ON N6G 2V4, Canada
| | - Constantine A Stratakis
- Internal Medicine-Endocrinology, Hypertension and Metabolic Genetics, Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 10 Center Drive, MSC 1109, Bethesda, MD 20892, USA
| | - Christian A Koch
- The University of Tennessee Health Science Center, 910 Madison Avenue, Memphis, TN 38163, USA
| |
Collapse
|
14
|
Kim S, Kim MJ, Jeon J, Jang HR, Park KB, Huh W, Do YS, Kim YG, Kim DJ, Oh HY, Lee JE. Effects of percutaneous angioplasty on kidney function and blood pressure in patients with atherosclerotic renal artery stenosis. Kidney Res Clin Pract 2019; 38:336-346. [PMID: 31234613 PMCID: PMC6727892 DOI: 10.23876/j.krcp.18.0148] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 03/14/2019] [Accepted: 03/28/2019] [Indexed: 12/11/2022] Open
Abstract
Background Previous randomized controlled trials of revascularization for atherosclerotic renal artery stenosis (ARAS) were not successful. We investigated the effects of percutaneous transluminal angioplasty with stent insertion (PTA/S) on kidney function and blood pressure (BP) control in patients with ARAS. Methods From 2000 to 2017, 47 subjects who underwent PTA/S for ARAS were identified. A high-risk group was defined, composed of patients having one or more of the following clinical presentations: pulmonary edema, refractory hypertension, and rapid deterioration of kidney function. Subjects who met the criteria of 'kidney function improvement' or 'hypertension improvement' after PTA/S were classified as responders. Results Twenty-one (44.7%) subjects were classified into the high-risk group. Two subjects (8.0%) in the low-risk group (n = 25) and 5 subjects (27.8%) in the high-risk group (n = 18) showed improvement in kidney function after PTA/S (P = 0.110). In patients with rapid decline of kidney function, estimated glomerular filtration rate improved from 28 (interquartile range [IQR], 10-45) mL/min/1.73 m2 to 41 (IQR, 16-67) mL/min/1.73 m2 at 4 months after PTA/S, although the difference was not significant (P = 0.084). Regarding BP control, 9 (36.0%) and 14 (77.8%) subjects showed improvement after PTA/S in the low- (n = 25) and high-risk (n = 18) groups, respectively (P = 0.007). In patients with refractory hypertension, the systolic BP dropped from 157 (IQR, 150-164) mmHg to 140 (IQR, 131-148) mmHg at 4 months after PTA/S (P = 0.005). Twenty-five subjects were defined as responders and comprised a significant proportion of the high-risk group (P = 0.004). Conclusion PTA/S might improve BP control and kidney function in patients with ARAS presenting with high-risk clinical features. The optimal application of PTA/S should be based on individual assessment of the clinical significance of renal artery stenosis.
Collapse
Affiliation(s)
- Suhyun Kim
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mi Jeoung Kim
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Internal Medicine, Incheon Sarang Hospital, Incheon, Korea
| | - Jeunseok Jeon
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Ryoun Jang
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Bo Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wooseong Huh
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Soo Do
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon-Goo Kim
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dae Joong Kim
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ha Young Oh
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Eun Lee
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
15
|
Sakuma I, Saito J, Matsuzawa Y, Omura M, Matsui S, Nishikawa T. A Unique Case of Renovascular Hypertension due to Fibromuscular Dysplasia in an Extra-renal Artery. Intern Med 2018; 57:2689-2694. [PMID: 29709926 PMCID: PMC6191605 DOI: 10.2169/internalmedicine.0023-17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
A 33-year-old man was admitted to our hospital to undergo an evaluation to determine the cause of secondary hypertension. Computerized tomography angiography (CTA) showed bilateral multiple renal arteries with significant stenosis of the right extra-renal artery due to fibromuscular dysplasia and segmental impairment of renal perfusion. Although the plasma aldosterone concentration and plasma renin activity were within the normal ranges, percutaneous balloon dilatation of the stenotic lesion resolved his hypertension, leading to a diagnosis of renovascular hypertension caused by segmental renal ischemia due to extra-renal artery stenosis. CTA should be considered during the examination of patients with early-age hypertension, even if the plasma renin activity is not sufficiently elevated.
Collapse
Affiliation(s)
- Ikki Sakuma
- Endocrinology & Diabetes Center, Yokohama Rosai Hospital, Japan
- Department of Clinical Cell Biology & Medicine, Chiba University Graduate School of Medicine, Japan
| | - Jun Saito
- Endocrinology & Diabetes Center, Yokohama Rosai Hospital, Japan
| | - Yoko Matsuzawa
- Endocrinology & Diabetes Center, Yokohama Rosai Hospital, Japan
| | - Masao Omura
- Endocrinology & Diabetes Center, Yokohama Rosai Hospital, Japan
| | - Seiji Matsui
- Department of Radiology, Yokohama Rosai Hospital, Japan
| | | |
Collapse
|
16
|
Herrmann SM, Textor SC. Current Concepts in the Treatment of Renovascular Hypertension. Am J Hypertens 2018; 31:139-149. [PMID: 28985335 DOI: 10.1093/ajh/hpx154] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Renovascular disease (RVD) remains a major cause of secondary and treatment-resistant hypertension. Most cases are related either to fibromuscular or atherosclerotic lesions, but a variety of other causes including arterial dissection, stent occlusion, and embolic disease can produce the same syndrome. Recent studies emphasize the kidney's tolerance to moderate flow reduction during antihypertensive drug therapy and the relative safety of medical therapy to control blood pressure. Several prospective trials in moderate RVD fail to identify major benefits from endovascular revascularization for moderate atherosclerotic disease. However, high-risk and progressive renovascular syndromes are recognized to be relatively refractory to medical therapy only and respond better to combining renal revascularization with ongoing medical therapy. Clinicians caring for complex hypertension should be familiar with pathogenic pathways, imaging techniques, and a rational approach to managing renovascular hypertension in the current era.
Collapse
Affiliation(s)
- Sandra M Herrmann
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Stephen C Textor
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
17
|
|
18
|
Morisawa N, Sugano N, Yamakawa T, Kuriyama S, Yokoo T. Successful long-term effects of direct renin inhibitor aliskiren in a patient with atherosclerotic renovascular hypertension. CEN Case Rep 2017; 6:66-73. [DOI: 10.1007/s13730-016-0246-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 12/24/2016] [Indexed: 11/24/2022] Open
|
19
|
Drummond CA, Brewster PS, He W, Ren K, Xie Y, Tuttle KR, Haller ST, Jamerson K, Dworkin LD, Cutlip DE, Murphy TP, D’Agostino RB, Henrich WL, Tian J, Shapiro JI, Cooper CJ. Cigarette smoking and cardio-renal events in patients with atherosclerotic renal artery stenosis. PLoS One 2017; 12:e0173562. [PMID: 28306749 PMCID: PMC5357000 DOI: 10.1371/journal.pone.0173562] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 02/22/2017] [Indexed: 11/22/2022] Open
Abstract
Cigarette smoking causes cardiovascular disease and is associated with poor kidney function in individuals with diabetes mellitus and primary kidney diseases. However, the association of smoking on patients with atherosclerotic renal artery stenosis has not been studied. The current study utilized data from the Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL, NCT00081731) clinical trial to evaluate the effects of smoking on the risk of cardio-renal events and kidney function in this population. Baseline data showed that smokers (n = 277 out of 931) were significantly younger at enrollment than non-smokers (63.3±9.1 years vs 72.4±7.8 years; p<0.001). In addition, patients who smoke were also more likely to have bilateral renal artery stenoses and peripheral vascular disease (PVD). Longitudinal analysis showed that smokers experienced composite endpoint events (defined as first occurrence of: stroke; cardiovascular or renal death; myocardial infarction; hospitalization for congestive heart failure; permanent renal replacement; and progressive renal insufficiency defined as 30% reduction of GFR from baseline sustained for ≥ 60 days) at a substantially younger age compared to non-smokers (67.1±9.0 versus 76.1±7.9, p<0.001). Using linear regression and generalized linear modeling analysis controlled by age, sex, and ethnicity, smokers had significantly higher cystatin C levels (1.3±0.7 vs 1.2±0.9, p<0.01) whereas creatinine and estimated glomerular filtration rate (eGFR) were not different from non-smokers. From these data we conclude that smoking has a significant association with deleterious cardio-renal outcomes in patients with renovascular hypertension.
Collapse
Affiliation(s)
- Christopher A. Drummond
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States of America
| | - Pamela S. Brewster
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States of America
| | - Wencan He
- Department of Mathematics, University of Toledo, Toledo, OH, United States of America
| | - Kaili Ren
- Department of Mathematics, University of Toledo, Toledo, OH, United States of America
| | - Yanmei Xie
- Department of Mathematics, University of Toledo, Toledo, OH, United States of America
| | - Katherine R. Tuttle
- Division of Nephrology, University of Washington School of Medicine, Providence Health Care, Spokane, WA, United States of America
| | - Steven T. Haller
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States of America
| | - Kenneth Jamerson
- Department of Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Lance D. Dworkin
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States of America
| | - Donald E. Cutlip
- Harvard Clinical Research Institute, Boston, MA, United States of America
| | - Timothy P. Murphy
- Departments of Medicine and Diagnostic Imaging, Rhode Island Hospital and Alpert Medical School of Brown University, Providence, RI, United States of America
| | | | - William L. Henrich
- University of Texas Health Science Center, San Antonio TX, United States of America
| | - Jiang Tian
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States of America
| | - Joseph I. Shapiro
- Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, United States of America
| | - Christopher J. Cooper
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States of America
| |
Collapse
|
20
|
Hypertension: The role of biochemistry in the diagnosis and management. Clin Chim Acta 2016; 465:131-143. [PMID: 28007614 DOI: 10.1016/j.cca.2016.12.014] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Revised: 12/11/2016] [Accepted: 12/14/2016] [Indexed: 01/10/2023]
Abstract
Hypertension is defined as a persistently elevated blood pressure ≥140/90mmHg. It is an important treatable risk factor for cardiovascular disease, with a high prevalence in the general population. The most common cause, essential hypertension, is a widespread disease - however, secondary hypertension is under investigated and under diagnosed. Collectively, hypertension is referred to as a "silent killer" - frequently it displays no overt symptomatology. It is a leading risk factor for death and disability globally, with >40% of persons aged over 25 having hypertension. A vast spectrum of conditions result in hypertension spanning essential through resistant, to patients with an overt endocrine cause. A significant number of patients with hypertension have multiple cardiovascular risk factors at the time of presentation. Both routine and specialised biochemical investigations are paramount for the evaluation of these patients and their subsequent management. Biochemical testing serves to identify those hypertensive individuals who are at higher risk on the basis of evidence of dysglycaemia, dyslipidaemia, renal impairment, or target organ damage and to exclude identifiable causes of hypertension. The main target of biochemical testing is the identification of patients with a specific and treatable aetiology of hypertension. Information gleaned from biochemical investigation is used to risk stratify patients and tailor the type and intensity of subsequent management and treatment. We review the approach to the biochemical investigation of patients presenting with hypertension and propose a diagnostic algorithm for work-up.
Collapse
|
21
|
Fournier T, Sens F, Rouvière O, Millon A, Juillard L. [Management of atherosclerotic renal-artery stenosis in 2016]. Nephrol Ther 2016; 13:1-8. [PMID: 27887845 DOI: 10.1016/j.nephro.2016.07.450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 07/09/2016] [Accepted: 07/11/2016] [Indexed: 11/26/2022]
Abstract
Endovascular revascularization as treatment of atherosclerotic renal-artery stenosis (aRAS) is controversial since 3 large and multicentric randomised trials (CORAL, ASTRAL, STAR) failed to prove the superiority of percutaneous transluminal renal-artery stenting (PTRAS) over medical treatment only (MT). However, considering the multiple bias of these trials, among which questionable inclusion criterias, these results must be extrapolated in clinical practice with caution. New pathophysiological data have been helping to understand why restoring blood flow does not necessarily lead to kidney function improvement. Today, the diagnostic approach must in one hand confirm the artery stenosis and on the other hand assess its severity and impact on the kidney. Therapeutic options still lie on the American guidelines published in 2006, since no study data can be reasonably used in everyday practice. However, particular sub-groups of patients who could benefit from revascularisation have been identified through recent cohort studies. Further prospective studies are needed in order to confirm the superiority of PTRAS in these populations. Meanwhile, multidisciplinary approach should be promoted, in order to provide the best treatment for each patient.
Collapse
Affiliation(s)
- Thomas Fournier
- Service de néphrologie, hôpital Édouard-Herriot, hospices civils de Lyon, 5, place d'Arsonval, 69003 Lyon, France; Université Lyon 1, 43, boulevard du 11-novembre-1918, 69622 Villeurbanne cedex, France.
| | - Florence Sens
- Service de néphrologie, hôpital Édouard-Herriot, hospices civils de Lyon, 5, place d'Arsonval, 69003 Lyon, France; Université Lyon 1, 43, boulevard du 11-novembre-1918, 69622 Villeurbanne cedex, France; Pôle IMER, site Lacassagne, hospices civils de Lyon, 5, place d'Arsonval, 69003 Lyon, France
| | - Olivier Rouvière
- Université Lyon 1, 43, boulevard du 11-novembre-1918, 69622 Villeurbanne cedex, France; Service d'imagerie vasculaire et urinaire, hôpital Édouard-Herriot, hospices civils de Lyon, 5, place d'Arsonval, 69003 Lyon, France
| | - Antoine Millon
- Université Lyon 1, 43, boulevard du 11-novembre-1918, 69622 Villeurbanne cedex, France; Service de chirurgie vasculaire, hôpital Édouard-Herriot, hospices civils de Lyon, 5, place d'Arsonval, 69003 Lyon, France
| | - Laurent Juillard
- Service de néphrologie, hôpital Édouard-Herriot, hospices civils de Lyon, 5, place d'Arsonval, 69003 Lyon, France; Université Lyon 1, 43, boulevard du 11-novembre-1918, 69622 Villeurbanne cedex, France; OPeRa, Carmen, université Lyon 1, 11, avenue Jean-Capelle, 69621 Villeurbanne cedex, France
| |
Collapse
|
22
|
Spezia L, Perandini S, Augelli R, Puppini G, Montemezzi S. Successful Treatment of Resistant Hypertension by Means of Chronic Renal Artery Occlusion Revascularization in a Fragile Patient. Pol J Radiol 2016; 81:532-535. [PMID: 27882189 PMCID: PMC5108372 DOI: 10.12659/pjr.898713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 04/22/2016] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Renal artery stenosis is a common cause of secondary hypertension refractory to medical therapy. Percutaneous angioplasty along with metallic stent placement has been described as an effective treatment for revascularization of the renal artery. CASE REPORT A 54-year-old woman affected by paranoid schizophrenia with a history of hypertension and chronic renal failure due to renal artery occlusion was treated by endovascular recanalization and stent placement that resulted in improvement of renal function and control of hypertension. Laboratory studies 4 months after the revascularization revealed blood creatinine decrease gradually from 8.57 mg/dL to 3 mg/dL. CONCLUSIONS Revascularization with stenting has proven to be a safe and effective procedure in the treatment of total renal artery occlusion which also led to a significant relief at a psychological level.
Collapse
Affiliation(s)
- Laura Spezia
- Department of Radiology, Azienda Ospedaliera Universitaria Integrata (AOUI), Verona, Italy
| | - Simone Perandini
- Department of Radiology, Azienda Ospedaliera Universitaria Integrata (AOUI), Verona, Italy
| | - Raffaele Augelli
- Department of Radiology, Fondazione Poliambulanza Brescia, Brescia, Italy
| | - Giovanni Puppini
- Department of Radiology, Azienda Ospedaliera Universitaria Integrata (AOUI), Verona, Italy
| | - Stefania Montemezzi
- Department of Radiology, Azienda Ospedaliera Universitaria Integrata (AOUI), Verona, Italy
| |
Collapse
|
23
|
Daloul R, Morrison AR. Approach to atherosclerotic renovascular disease: 2016. Clin Kidney J 2016; 9:713-21. [PMID: 27679718 PMCID: PMC5036906 DOI: 10.1093/ckj/sfw079] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 07/20/2016] [Indexed: 12/20/2022] Open
Abstract
The management of atherosclerotic renal artery stenosis in patients with hypertension or impaired renal function remains a clinical dilemma. The current general consensus, supported by the results of the Angioplasty and Stenting for Renal Atherosclerotic Lesions and Cardiovascular Outcomes for Renal Artery Lesions trials, argues strongly against endovascular intervention in favor of optimal medical management. We discuss the limitations and implications of the contemporary clinical trials and present our approach and formulate clear recommendations to help with the management of patients with atherosclerotic narrowing of the renal artery.
Collapse
Affiliation(s)
- Reem Daloul
- Renal Division, Department of Internal Medicine , Washington University School of Medicine , 660 South Euclid, Box 8126, St Louis, MO 63110 , USA
| | - Aubrey R Morrison
- Renal Division, Department of Internal Medicine , Washington University School of Medicine , 660 South Euclid, Box 8126, St Louis, MO 63110 , USA
| |
Collapse
|
24
|
Jujo K, Saito K, Ishida I, Furuki Y, Ouchi T, Kim A, Suzuki Y, Sekiguchi H, Yamaguchi J, Ogawa H, Hagiwara N. Efficacy of 24-Hour Blood Pressure Monitoring in Evaluating Response to Percutaneous Transluminal Renal Angioplasty. Circ J 2016; 80:1922-30. [PMID: 27439675 DOI: 10.1253/circj.cj-16-0347] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Percutaneous transluminal renal angioplasty (PTRA) improves patency in atherosclerotic renal artery stenosis (ARAS), but improvement in clinic blood pressure (BP) is seen in only 20-40% of patients who undergo PTRA. This study investigated the effects of PTRA on BP lowering, assessed on 24-h ambulatory BP monitoring (ABPM), and identified preoperative features predictive of satisfactory BP improvement after PTRA. METHODS AND RESULTS Of 1,753 consecutive patients undergoing coronary angiography, 31 patients with angiographically significant ARAS and translesional pressure gradient (TLPG) >20 mmHg underwent PTRA. ABPM was performed before, at 1 month and at 1 year after PTRA; patients with average systolic ABPM-BP decrease >10 mmHg at 1 month from baseline were categorized as responders. There was no obvious relationship between clinic BP and ABPM-BP at baseline. ABPM-BP was significantly higher in responders at baseline (SBP: 148 vs. 126 mmHg, P<0.01) and was improved 1 month after PTRA. This difference persisted until 1 year after PTRA. Night-time BP improved more than daytime BP in responders. Patients with higher baseline ABPM-BP achieved a larger decrease in ABPM-BP, but the severity of stenosis reflected by TLPG; renal duplex findings; and neurohumoral parameters other than baseline renal function, did not differ between the groups. CONCLUSIONS Clinic BP does not represent daily hemodynamic status, whereas high ABPM-BP is a potent predictor of satisfactory BP response to PTRA. (Circ J 2016; 80: 1922-1930).
Collapse
Affiliation(s)
- Kentaro Jujo
- Department of Cardiology, Tokyo Women's Medical University
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
O’Connor PJ, Lookstein RA. Endovascular Treatment of Renal Artery Stenosis in the Post CORAL Era. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:48. [DOI: 10.1007/s11936-016-0474-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
26
|
Patel SM, Li J, Parikh SA. Renal Artery Stenosis: Optimal Therapy and Indications for Revascularization. Curr Cardiol Rep 2016; 17:623. [PMID: 26238738 DOI: 10.1007/s11886-015-0623-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Atherosclerotic renal artery stenosis (ARAS) is associated with increased cardiovascular risk and overall mortality. Manifestations of ARAS include resistant or malignant hypertension, progressive deterioration of renal function, and cardiac dysfunction syndromes of flash pulmonary edema and angina. Diagnosis rests upon non-invasive studies such as duplex ultrasonography and is confirmed using invasive renal arteriography. Regardless of the severity of ARAS, management of this entity has been a topic of contentious debate. For over two decades, the use of percutaneous revascularization to treat ARAS has been studied with various clinical trials. Though case series seem to demonstrate favorable clinical response to revascularization, the overwhelming majority of randomized clinical trials have not mirrored a robust outcome. In these trials, poor correlation is noted between the reduction of stenosis and the improvement of renovascular hypertension and glomerular filtration rate, and decrease in cardiovascular outcomes and mortality. With dichotomizing results, the explanation for these discrepant findings has been attributed to improper trial design and inappropriate patient selection. An overview of the treatment options available will be provided, with a focus on the methodology and design of clinical trials investigating the efficacy of percutaneous revascularization. Emphasis is placed on appropriate patient selection criteria, which may necessitate the use of hemodynamic lesion assessment and clinical correlation based on individualized care. When clinical equipoise exists between optimal medical therapy and revascularization, the current paradigm supports ongoing medical therapy as the treatment of choice. However, renal artery stenting remains a viable therapeutic option for those who continue to have clinical syndromes consistent with renal hypoperfusion while adequately treated with optimal medical therapy. Despite observational studies suggesting clinical benefit for this specific patient population, there remains a paucity of randomized clinical trial data. Further trials targeting the patients who are inadequately treated with optimal medical therapy need to be undertaken to confirm the efficacy of revascularization.
Collapse
Affiliation(s)
- Sandeep M Patel
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | | | | |
Collapse
|
27
|
Attenuation of hypertension and renal damage in renovascular hypertensive rats by iron restriction. Hypertens Res 2016; 39:832-839. [PMID: 27439494 DOI: 10.1038/hr.2016.93] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 06/06/2016] [Accepted: 06/16/2016] [Indexed: 12/21/2022]
Abstract
Iron is a catalyst in the formation of reactive oxygen species. Oxidative stress is associated with the pathogenesis of both human and experimental animal models of renovascular hypertension. We hypothesized that iron is involved in the pathogenesis of renovascular hypertension and that iron restriction may affect the pathogenesis of renovascular hypertension via the inhibition of oxidative stress. Herein, we investigated the effect of iron restriction on hypertension and renal damage in a rat model of two-kidney one-clip (2K1C) renovascular hypertension. Renovascular hypertension was induced by 2K1C in male Sprague-Dawley rats. At the day of clipping, 2K1C rats were divided into untreated (2K1C) and dietary iron-restricted groups (2K1C+IR). The 2K1C rats showed hypertension after the day of clipping, whereas dietary iron restriction attenuated the development of hypertension. Vascular hypertrophy and the increased fibrotic area were suppressed in the 2K1C+IR group. The clipped kidney developed renal atrophy in both the 2K1C and 2K1C+IR groups after clipping. However, the unclipped kidney showed renal hypertrophy in the 2K1C and 2K1C+IR groups, and the extent was less in the 2K1C+IR group. The 2K1C rats exhibited glomerulosclerosis and tubulointerstitial fibrosis in the unclipped kidney, whereas these changes were attenuated by an iron-restricted diet. Importantly, proteinuria was decreased in the 2K1C+IR group, along with decreased urinary 8-hydroxy-2'-deoxyguanosine excretion and superoxide production of the unclipped kidney. Moreover, the expression of nuclear mineralocorticoid receptor in the unclipped kidney of the 2K1C rats was attenuated by iron restriction. These data indicate a novel effect of iron restriction on hypertension and renal damage in renovascular hypertension.
Collapse
|
28
|
Affiliation(s)
- Michele Petruzzelli
- From the Clinical Pharmacology Unit (M.P., M.J.B.) and Department of Oncology (M.P.), University of Cambridge, Cambridge, United Kingdom; Clinical Biochemistry (K.P.T.) and Department of Radiology (B.K.), Addenbrooke’s Hospital, Cambridge, United Kingdom; Departments of Clinical Pharmacology and Endocrinology, William Harvey Research Institute, Queen Mary University London, London, United Kingdom (M.J.B.)
| | - Kevin P. Taylor
- From the Clinical Pharmacology Unit (M.P., M.J.B.) and Department of Oncology (M.P.), University of Cambridge, Cambridge, United Kingdom; Clinical Biochemistry (K.P.T.) and Department of Radiology (B.K.), Addenbrooke’s Hospital, Cambridge, United Kingdom; Departments of Clinical Pharmacology and Endocrinology, William Harvey Research Institute, Queen Mary University London, London, United Kingdom (M.J.B.)
| | - Brendan Koo
- From the Clinical Pharmacology Unit (M.P., M.J.B.) and Department of Oncology (M.P.), University of Cambridge, Cambridge, United Kingdom; Clinical Biochemistry (K.P.T.) and Department of Radiology (B.K.), Addenbrooke’s Hospital, Cambridge, United Kingdom; Departments of Clinical Pharmacology and Endocrinology, William Harvey Research Institute, Queen Mary University London, London, United Kingdom (M.J.B.)
| | - Morris J. Brown
- From the Clinical Pharmacology Unit (M.P., M.J.B.) and Department of Oncology (M.P.), University of Cambridge, Cambridge, United Kingdom; Clinical Biochemistry (K.P.T.) and Department of Radiology (B.K.), Addenbrooke’s Hospital, Cambridge, United Kingdom; Departments of Clinical Pharmacology and Endocrinology, William Harvey Research Institute, Queen Mary University London, London, United Kingdom (M.J.B.)
| |
Collapse
|
29
|
Affiliation(s)
| | - Stephen R. Ramee
- Department of Cardiology, Ochsner Clinic, New Orleans, Louisiana, USA
| | - Tyrone J. Collins
- Department of Cardiology, Ochsner Clinic, New Orleans, Louisiana, USA
| | | |
Collapse
|
30
|
Atherosclerotic Renal Artery Stenosis and Hypertension: Pragmatism, Pitfalls, and Perspectives. Am J Med 2016; 129:635.e5-635.e14. [PMID: 26522797 DOI: 10.1016/j.amjmed.2015.10.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 10/07/2015] [Accepted: 10/08/2015] [Indexed: 11/21/2022]
Abstract
For many years and even decades, a diagnostic work-up to look for a secondary form of hypertension, particularly of renovascular origin, has been a central tenet in medicine. Atherosclerotic renal artery stenosis is considered the most common cause of renovascular hypertension. However, advances in understanding the complex pathophysiology of this condition and the recently documented futility of renal revascularization bring into question whether atherosclerotic renal artery stenosis truly causes "renovascular hypertension." From a clinical point of view, a clear distinction should be made between hypertension associated with atherosclerotic renal artery stenosis and hypertension caused by renal artery stenosis-induced activation of the renin-angiotensin-aldosterone system. Most patients with atherosclerotic renal artery stenosis do not have a form of hypertension that is remediable or improved by angioplasty; to expose them to the cost, inconvenience, and risk of a diagnostic work-up add up to little more than a wild goose chase. However, with very few exceptions, medical therapy with antihypertensives and statins remains the cornerstone for the management of patients with atherosclerotic renal artery stenosis and hypertension.
Collapse
|
31
|
Zhu Y, Ren J, Ma X, Chen MH, Zhou Y, Jin M, Liu Z. Percutaneous Revascularization for Atherosclerotic Renal Artery Stenosis: A Meta-Analysis of Randomized Controlled Trials. Ann Vasc Surg 2015; 29:1457-67. [DOI: 10.1016/j.avsg.2015.06.062] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Revised: 05/30/2015] [Accepted: 06/21/2015] [Indexed: 10/23/2022]
|
32
|
The utility of renal venous renin studies in selection of patients with renal artery stenosis for angioplasty. J Hypertens 2015; 33:1931-8; discussion 1938. [DOI: 10.1097/hjh.0000000000000635] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
33
|
Schäberle W, Leyerer L, Schierling W, Pfister K. Ultrasound diagnostics of renal artery stenosis: Stenosis criteria, CEUS and recurrent in-stent stenosis. GEFASSCHIRURGIE 2015; 21:4-13. [PMID: 27034579 PMCID: PMC4767855 DOI: 10.1007/s00772-015-0060-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background and purpose As a non-invasive, side effect-free and cost-effective method, ultrasonography represents the method of choice for the diagnosis of renal artery stenosis. Four different criteria in total, including two direct criteria in peak systolic velocity (PSV) and renal aortic ratio (RAR) and two indirect criteria in resistance index (RI) and acceleration time (AT) for the measurement of relevant renal artery stenosis are described, each demonstrating highly variable accuracy in studies. Furthermore, there is controversy over the degree beyond which stenosis becomes therapeutically relevant and which ultrasound PSV is diagnostically relevant in terms of stenosis grading. Material and methods This article gives a critical review based on a selective literature search on measurement methodology and the validity of ultrasound in renal artery stenosis. A critical evaluation of methods and a presentation of measurement principles to establish the most precise measurement method possible compared with the gold standard angiography, as well as an evaluation of the importance of computed tomography angiography (CTA) and magnetic resonance angiography (MRA). Results and conclusions The PSV provides high sensitivity and specificity as a direct measurement method in stenosis detection and grading. Most studies found sensitivities and specificities of 85–90 % for > 50 % stenosis at a PSV > 180–200 cm/s in ROC curve analysis. Other methods, such as the ratio of the PSV in the aorta to the PSV in the renal artery (RAR) or indirect criteria, such as side to side differences in RI (dRI) or AT can be additionally used to improve accuracy. Contrast-enhanced ultrasound improves accuracy by means of echo contrast enhancement. Although in the past only high-grade stenosis was considered relevant for treatment, a drop in pressure of > 20 mmHg in > 50 % stenosis (PSV 180 cm/s) is classified as relevant for increased renin secretion. Stenosis in fibromuscular dysplasia can be reliably graded according to the continuity equation. Although the available studies on the grading of in-stent restenosis are the subject of controversy, there is a tendency to assume higher cut-off values for PSV and RAR. Whilst MRA and CTA demonstrate an accuracy of > 90 %, this is at the cost of possible side effects for patients, particularly in the case of pre-existing renal parenchymal damage. Additional online material This article includes two additional video sequences on visualizing renal artery stenosis. This supplemental material can be found under: dx.doi.org/10.1007/s00772-015-0060-3
Collapse
Affiliation(s)
- W Schäberle
- Department of Visceral, Vascular, Thorax and Pediatric Surgery, "Klinik am Eichert", Eichertstr. 3, 73035 Göppingen, Germany
| | - L Leyerer
- Department of Visceral, Vascular, Thorax and Pediatric Surgery, "Klinik am Eichert", Eichertstr. 3, 73035 Göppingen, Germany
| | - W Schierling
- Vascular and Endovascular Surgery, Regensburg University Hospital, Regensburg, Germany
| | - K Pfister
- Vascular and Endovascular Surgery, Regensburg University Hospital, Regensburg, Germany
| |
Collapse
|
34
|
Effects of rolipram and roflumilast, phosphodiesterase-4 inhibitors, on hypertension-induced defects in memory function in rats. Eur J Pharmacol 2015; 746:138-47. [DOI: 10.1016/j.ejphar.2014.10.039] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Revised: 10/16/2014] [Accepted: 10/18/2014] [Indexed: 12/17/2022]
|
35
|
Jenks S, Yeoh SE, Conway BR. Balloon angioplasty, with and without stenting, versus medical therapy for hypertensive patients with renal artery stenosis. Cochrane Database Syst Rev 2014; 2014:CD002944. [PMID: 25478936 PMCID: PMC7138037 DOI: 10.1002/14651858.cd002944.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Atherosclerotic renal artery stenosis is the most common cause of secondary hypertension. Balloon angioplasty with stenting is widely used for the treatment of hypertensive patients with renal artery stenosis but the effectiveness of this procedure in treating hypertension, improving renal function and preventing adverse cardiovascular and renal events remains uncertain. This is an update, to include the results of recent, important large trials, of a review first published in 2003. OBJECTIVES To compare the effectiveness of balloon angioplasty (with and without stenting) with medical therapy for the treatment of atherosclerotic renal artery stenosis in patients with hypertension. The following outcomes were compared: blood pressure control, renal function, frequency of cardiovascular and renal adverse events, presence or absence of restenosis of the renal artery, side effects of medical therapy, numbers and defined daily doses of antihypertensive drugs. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched May 2014) and CENTRAL (2014, Issue 4). Bibliographies were also reviewed and trial authors were contacted for more information. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing balloon angioplasty with medical therapy in hypertensive patients with haemodynamically significant renal artery stenosis (greater than 50% reduction in luminal diameter) and with a minimum follow-up of six months. DATA COLLECTION AND ANALYSIS Data were extracted independently on trial design, participants, interventions and outcome measures. A formal meta-analysis was completed to assess the effect on blood pressure, renal function and cardiovascular and renal adverse events. Peto's odds ratios (ORs) and corresponding 95% confidence intervals (CI) for dichotomous outcomes and mean differences (MD) and corresponding 95% CIs for continuous variables were calculated. MAIN RESULTS Eight RCTs involving 2222 participants with renal artery stenosis were included in the review. The overall quality of evidence included in this review was moderate. Limited pooling of results was possible due to the variable presentation of some of the trial outcomes. Meta-analysis of the four studies reporting change in diastolic blood pressure (BP) found a small improvement in diastolic BP in the angioplasty group (MD -2.00 mmHg; 95% CI -3.72 to -0.27) whilst the meta-analysis of the five studies reporting change in systolic BP did not find any evidence of significant improvement (MD -1.07 mmHg; 95% CI -3.45 to 1.30). There was no significant effect on renal function as measured by serum creatinine (MD -7.99 µmol/L; 95% CI -22.6 to 6.62). Meta-analysis of the three studies that reported the mean number of antihypertensive drugs found a small decrease in antihypertensive drug requirements for the angioplasty group (MD -0.18; 95% CI -0.34 to -0.03). Repeat angiography was only performed on a small number of participants in a single trial and it was therefore not possible to comment on restenosis of the renal artery following balloon angioplasty. Based on the results of the seven studies that reported cardiovascular and renal clinical outcomes there were no differences in cardiovascular (OR 0.91; 95% CI 0.75 to 1.11) or renal adverse events (OR 1.02; 95% CI 0.75 to 1.38) between the angioplasty and medical treatment groups. A small number of procedural complications of balloon angioplasty were reported (haematoma at the site of catheter insertion (6.5%), femoral artery pseudoaneurysm (0.7%), renal artery or kidney perforation or dissection (2.5%) as well as peri-procedural deaths (0.4%)). No side effects of medical therapy were reported. AUTHORS' CONCLUSIONS The available data are insufficient to conclude that revascularisation in the form of balloon angioplasty, with or without stenting, is superior to medical therapy for the treatment of atherosclerotic renal artery stenosis in patients with hypertension. However, balloon angioplasty results in a small improvement in diastolic blood pressure and a small reduction in antihypertensive drug requirements. Balloon angioplasty appears safe and results in similar numbers of cardiovascular and renal adverse events to medical therapy.
Collapse
Affiliation(s)
- Sara Jenks
- Centre for Population Health Sciences, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, UK.
| | | | | |
Collapse
|
36
|
Abstract
Severe atherosclerotic renal artery stenosis can manifest as treatment-resistant hypertension, ischemic nephropathy and/or cardiac disturbance syndromes of recurrent flash pulmonary edema and refractory angina. Renal artery revascularization can dramatically impact patient outcome. However, patient selection for revascularization can be challenging. Renal artery stenting is most commonly used for renal revascularization and is a safe procedure when performed in carefully selected patients. This review addresses the pathophysiology of renal artery stenosis and the data supporting revascularization in such patients.
Collapse
Affiliation(s)
- Jun Li
- Department of Medicine, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA; Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Sahil A Parikh
- Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA; Interventional Cardiology Fellowship Program, Experimental Interventional Cardiology Laboratory, Department of Medicine, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
| |
Collapse
|
37
|
Balamuthusamy S, Kannan A, Thajudeen B, Ottley D, Jalandhara N. Mild Renal Artery Stenosis Can Induce Renovascular Hypertension and is Associated with Elevated Renal Vein Renin Secretion. Semin Dial 2014; 28:293-8. [PMID: 24943669 DOI: 10.1111/sdi.12256] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Renovascular hypertension is a syndrome which encompasses the physiological response of the kidney to changes in renal blood flow and renal perfusion pressure. Such physiological changes can occur with renal artery occlusion irrespective of the severity of the lesion. We have analyzed hypertensive patients with mild renal artery stenosis and compared them to patients with no stenosis. Renal vein renin sampling from catheterization of the renal vein was performed in all these patients. Patients with mild stenosis had higher renal vein renin ratio (3.01 ± 1.5) than the patients with no stenosis (1.10 ± 0.29; p = 0.002). Patients with mild stenosis were also found to have higher diastolic blood pressure and renal artery resistive indices when compared to patients with no stenosis. We therefore conclude that mild stenosis can precipitate renin-mediated hypertension in renovascular stenosis and also emphasis that parameters pertinent to renal physiology need to be evaluated before considering treatment options in patients with renal artery stenosis and medical management with RAAS blockade is the preferred modality of therapy for patients with renin-mediated hypertension.
Collapse
Affiliation(s)
- Saravanan Balamuthusamy
- Angiocare, Vascular and Interventional Nephrology, Tucson, Arizona; Department of Medicine, Nephrology Division, University of Arizona, Tucson, Arizona
| | | | | | | | | |
Collapse
|
38
|
Cooper CJ, Murphy TP, Cutlip DE, Jamerson K, Henrich W, Reid DM, Cohen DJ, Matsumoto AH, Steffes M, Jaff MR, Prince MR, Lewis EF, Tuttle KR, Shapiro JI, Rundback JH, Massaro JM, D'Agostino RB, Dworkin LD. Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med 2014; 370:13-22. [PMID: 24245566 PMCID: PMC4815927 DOI: 10.1056/nejmoa1310753] [Citation(s) in RCA: 583] [Impact Index Per Article: 58.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Atherosclerotic renal-artery stenosis is a common problem in the elderly. Despite two randomized trials that did not show a benefit of renal-artery stenting with respect to kidney function, the usefulness of stenting for the prevention of major adverse renal and cardiovascular events is uncertain. METHODS We randomly assigned 947 participants who had atherosclerotic renal-artery stenosis and either systolic hypertension while taking two or more antihypertensive drugs or chronic kidney disease to medical therapy plus renal-artery stenting or medical therapy alone. Participants were followed for the occurrence of adverse cardiovascular and renal events (a composite end point of death from cardiovascular or renal causes, myocardial infarction, stroke, hospitalization for congestive heart failure, progressive renal insufficiency, or the need for renal-replacement therapy). RESULTS Over a median follow-up period of 43 months (interquartile range, 31 to 55), the rate of the primary composite end point did not differ significantly between participants who underwent stenting in addition to receiving medical therapy and those who received medical therapy alone (35.1% and 35.8%, respectively; hazard ratio with stenting, 0.94; 95% confidence interval [CI], 0.76 to 1.17; P=0.58). There were also no significant differences between the treatment groups in the rates of the individual components of the primary end point or in all-cause mortality. During follow-up, there was a consistent modest difference in systolic blood pressure favoring the stent group (-2.3 mm Hg; 95% CI, -4.4 to -0.2; P=0.03). CONCLUSIONS Renal-artery stenting did not confer a significant benefit with respect to the prevention of clinical events when added to comprehensive, multifactorial medical therapy in people with atherosclerotic renal-artery stenosis and hypertension or chronic kidney disease. (Funded by the National Heart, Lung and Blood Institute and others; ClinicalTrials.gov number, NCT00081731.).
Collapse
Affiliation(s)
- Christopher J Cooper
- From the University of Toledo, Toledo, OH (C.J.C.); Rhode Island Hospital (T.P.M., L.D.D.) and Alpert Medical School of Brown University (T.P.M., L.D.D.) - both in Providence; Harvard Clinical Research Institute (D.E.C., J.M.M., R.B.D.), Beth Israel Deaconess Medical Center (D.E.C.), Massachusetts General Hospital (M.R.J.), Brigham and Women's Hospital (E.F.L.), and Boston University School of Public Health (R.B.D.) - all in Boston; University of Michigan, Ann Arbor (K.J.); University of Texas Health Science Center, San Antonio (W.H.); National Heart, Lung and Blood Institute, Bethesda, MD (D.M.R.); Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, Kansas City (D.J.C.); University of Virginia, Charlottesville (A.H.M.); University of Minnesota, Minneapolis (M.S.); Weill Cornell Medical Center, New York (M.R.P.); Providence Sacred Heart Medical Center and University of Washington School of Medicine, Spokane (K.R.T.); Marshall University, Huntington, WV (J.I.S.); and Holy Name Medical Center, Teaneck NJ (J.H.R.)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Zhang W, Qian Y, Lin J, Lv P, Karunanithi K, Zeng M. Hemodynamic analysis of renal artery stenosis using computational fluid dynamics technology based on unenhanced steady-state free precession magnetic resonance angiography: preliminary results. Int J Cardiovasc Imaging 2013; 30:367-75. [DOI: 10.1007/s10554-013-0345-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 12/01/2013] [Indexed: 12/01/2022]
|
40
|
Blockade of the renin-angiotensin system in hypertensive patients with atherosclerotic renal artery stenosis. Curr Hypertens Rep 2013; 15:497-505. [PMID: 23897422 DOI: 10.1007/s11906-013-0376-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Renin angiotensin system (RAS) blockers are generally considered as contraindicated when an atheromatous renal artery stenosis (ARAS) is diagnosed. The main reason is the fear of inducing renal ischemia and, hence, accelerating renal fibrosis and the progression towards end stage renal disease, albeit RAS blocker have been shown to be highly effective in controlling blood pressure. Part of the solution came by the development of the revascularization. There is now growing evidence showing no superiority of angioplasty over medical treatment on cardiovascular events and mortality, renal function and blood pressure control. Hence, RAS blockers resurfaced based on their proven beneficial effects on blood pressure control and cardiovascular prevention in high risk atherosclerotic patients. Thus, RAS blockers belong today to the standard treatment of hypertensive patients with ARAS. However they were not systematically prescribed in trials focusing on ARAS. The ongoing CORAL trial will give us further information on the place of this class of antihypertensive drugs in patients with ARAS.
Collapse
|
41
|
Yorgun H, Kabakçı G, Canpolat U, Aytemir K, Fatihoğlu G, Karakulak UN, Kaya EB, Şahiner L, Tokgözoğlu L, Oto A. Frequency and predictors of renal artery stenosis in hypertensive patients undergoing coronary angiography. Angiology 2013; 64:385-390. [PMID: 22773382 DOI: 10.1177/0003319712451900] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Renal artery stenosis (RAS) and coronary artery disease share common risk factors. We investigated the frequency and predictors of RAS among hypertensive patients who underwent elective coronary angiography. A total of 832 hypertensive patients underwent coronary and renal angiography at the same session. Renal artery stenosis was classified as mild, moderate, or severe. The study population consisted of 4 groups; 71.1% with normal renal arteries, 12.5% with mild, 8.9% with moderate, and 7.5% with severe RAS. The prevalence of significant (≥50%) RAS was 16.3%. The Gensini score showed a stepwise rise with increasing severity of RAS. Age, duration of hypertension, estimated glomerular filtration rate, Gensini score, and multivessel disease were independent predictors for the presence of RAS. Hypertensive patients with those risk factors might need detailed investigation for RAS which may affect their prognosis.
Collapse
|
42
|
Herrmann SMS, Textor SC. Diagnostic criteria for renovascular disease: where are we now? Nephrol Dial Transplant 2012; 27:2657-63. [PMID: 22802581 DOI: 10.1093/ndt/gfs254] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Renovascular disease, especially atherosclerotic renal artery stenosis (ARAS) in older subjects, is commonly encountered in clinical practice. This is at least in part due to the major advances in non-invasive imaging techniques that allow greater diagnostic sensitivity and accuracy than ever before. Despite increased awareness of ARAS, renal revascularization is less commonly performed, likely as a result of several prospective, randomized, clinical trials which fail to demonstrate major benefits of renal revascularization beyond medical therapy alone. Primary care physicians are less likely to investigate renovascular disease and nephrologists likely see more patients after a period of unsuccessful medical therapy with more advanced ARAS. The goal of this review is to revisit current diagnostic and therapeutic paradigms in order to characterize more clearly which patients will likely benefit from further evaluation and intensive treatment of renal artery stenosis.
Collapse
|
43
|
Cardiac events in hypertensive patients with renal artery stenosis treated with renal angioplasty or drug therapy: meta-analysis of randomized trials. Am J Hypertens 2012; 25:1209-14. [PMID: 22854636 DOI: 10.1038/ajh.2012.110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Cardiac outcome in patients with atherosclerotic renal artery stenosis (ARAS) undergoing percutaneous transluminal renal angioplasty (PTRA) or medical therapy is not yet completely clear. The aim of this study was to perform a meta-analysis of randomized controlled trials to compare the effect of PTRA and medical therapy on nonfatal myocardial infarction in patients with ARAS. METHODS We searched for articles reporting cardiovascular outcome, including nonfatal myocardial infarction, in patients with renal artery stenosis randomized to PTRA with/without stenting or medical therapy. RESULTS Five studies were identified. The pooled population consisted of 1,159 subjects who experienced 56 nonfatal myocardial infarctions. When compared with medical therapy, the overall relative risk (RR) was 0.85 (95% confidence interval (CI) 0.51-1.42), P = 0.55, for PTRA. There was no significant difference between PTRA and medical therapy according to procedural characteristics (with/without stent placement), mean serum creatinine at follow-up (higher or lower than 2.0 mg/dl), and maximum follow-up length (> or <2 years). CONCLUSIONS In patients with ARAS and hypertension, there is a lack of evidence supporting the superiority of PTRA over medical therapy in prevention of nonfatal myocardial infarction. Awaiting for results of ongoing trials, our data and previous data suggest that PTRA and drug therapy have a similar impact on cardiovascular risk reduction in patients with renal artery stenosis and hypertension.
Collapse
|
44
|
Jaïdane A, Ouertani H, Dorai A, Zouaoui C, Ibrahim H, Zidi B. [Association of renovascular hypertension and primary aldosteronism]. Rev Med Interne 2012; 33:700-2. [PMID: 23102642 DOI: 10.1016/j.revmed.2012.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Revised: 09/11/2012] [Accepted: 09/17/2012] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Renal artery stenosis is rarely associated with Conn adenoma. CASE REPORT We report a 27-year-old male patient who presented in 2001 with a severe high blood pressure associated with hypokaliemia. Radiologic investigations showed a left renal artery stenosis with agenesis of left kidney. A left nephrectomy was performed and blood pressure returned to normal with a single antihypertensive drug. Five years later, the patient again presented with severe high blood pressure. Laboratory studies revealed a low serum potassium level at 2.8 mmol/L associated with high urinary potassium excretion (84 mmol/24h) and a very high aldosterone/renin ratio (>462). Abdominal CT scan demonstrated a right adrenal mass. The patient underwent a right adrenalectomy (adenoma). Blood pressure returned to normal with a single antihypertensive. Serum potassium levels as well as aldosterone/renin ratio normalized. CONCLUSION We discussed whether the association between these two entities is merely fortuitous or conversely based on a causal relationship.
Collapse
Affiliation(s)
- A Jaïdane
- Service d'endocrinologie, hôpital militaire de Tunis, 1008 Montfleury, Tunis, Tunisie.
| | | | | | | | | | | |
Collapse
|
45
|
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.
Collapse
Affiliation(s)
- James Ritchie
- Vascular Research Group, The University of Manchester Academic Health Science Centre, Salford Royal Hospital, Salford, United Kingdom
| | | | | |
Collapse
|
46
|
Abstract
Optimal management of renal artery atherosclerotic occlusive disease has been widely debated and studied. Although the accepted invasive treatment has evolved into favoring balloon angioplasty and stenting, the indications for intervention or medical therapy have not been universally agreed upon. The Angioplasty and Stenting for Renal Artery Lesions (ASTRAL) trial was conducted to answer the question of whether medical therapy or angioplasty and stenting is the best treatment for hemodynamically significant renal artery stenosis. However, the ASTRAL trial's study design was faulty and therefore did not provide conclusive evidence to answer the question. The Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial was designed to answer the same question as to which treatment (medical or angioplasty and stent) is best for renal artery stenosis, and its methodologies took into consideration the weaknesses of the ASTRAL trial. Results are soon to be released.
Collapse
Affiliation(s)
- Timur P Sarac
- Department of Vascular Surgery, The Cleveland Clinic, Cleveland, OH 44195, USA.
| |
Collapse
|
47
|
Rump LC, Sellin L. [Medicinal or instrumental (corrected) therapy of renal artery stenosis?]. Internist (Berl) 2012; 53:760-5. [PMID: 22450771 DOI: 10.1007/s00108-012-3038-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Arteriosclerotic renal artery stenosis (RAS) has an increased incidence in patients with cardiovascular risk factors. Clinically RAS presents in some patients as secondary, sometimes resistant arterial hypertension and in others as chronic renal insufficiency, sometimes with acute renal failure and in a third group both symptoms are observed. Doppler ultrasound plays a central role in the diagnosis of RAS. Therapeutically, it is important to identify hemodynamically relevant RAS before interventional therapy is initiated. The therapy of RAS has been under intensive debate since the publication of randomized controlled trials (RCT) which showed that only a subset of RAS can be successfully treated by interventional therapy. Since then the medicinal therapy of RAS has gained more and more impact. The following questions are raised: which forms of RAS can be treated by which therapy? What is the best medicinal therapy to treat RAS? What substances are recommended?
Collapse
Affiliation(s)
- L C Rump
- Klinik für Nephrologie, Universitätsklinikum Düsseldorf, Moorenstrasse 5, Düsseldorf, Germany.
| | | |
Collapse
|
48
|
Shetty R, Biondi-Zoccai GGL, Abbate A, Amin MS, Jovin IS. Percutaneous renal artery intervention versus medical therapy in patients with renal artery stenosis: a meta-analysis. EUROINTERVENTION 2012; 7:844-51. [PMID: 22082580 DOI: 10.4244/eijv7i7a132] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
AIMS Patients with renal artery stenosis are treated with percutaneous intervention, but randomised studies are inconclusive. We aimed to compare renal percutaneous revascularisation versus medical therapy. METHODS AND RESULTS A systematic search for randomised controlled studies yielded three studies comparing renal angioplasty and two studies comparing renal angioplasty with stenting versus medical therapy, respectively. Six sets of data were extracted focusing on systolic and diastolic blood pressure as well as serum creatinine at follow-up. The five trials included 1,030 patients with renal artery stenosis. There was a trend toward, but no significant improvement in, systolic blood pressure (weighted mean difference [WMD] -2.76 mmHg, 95% confidence interval (CI) -5.71 to 0.18; p=0.07), diastolic blood pressure, (WMD -1.18 mmHg, 95% CI -2.69 to 0.32; p=0.12), or serum creatinine (WMD -7.26 mmol/L, 95% CI -14.99 to 0.47; p=0.07) in the patients who underwent percutaneous intervention compared to the medical therapy group. All but one trial showed at least a moderate overall bias risk. CONCLUSIONS We did not find a significant improvement in blood pressure or renal function in patients with renal artery stenosis treated with renal artery revascularisation compared to medical therapy alone. However, trial quality was a limitation.
Collapse
Affiliation(s)
- Ranjith Shetty
- Cardiovascular Division, Department of Internal Medicine, Virginia Commonwealth University Health System/Medical College of Virginia, Richmond, VA, USA
| | | | | | | | | |
Collapse
|
49
|
Sofroniadou S, Kassimatis T, Srirajaskanthan R, Reidy J, Goldsmith D. Long-term safety and efficacy of renin-angiotensin blockade in atherosclerotic renal artery stenosis. Int Urol Nephrol 2011; 44:1451-9. [PMID: 22127407 DOI: 10.1007/s11255-011-0091-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 11/10/2011] [Indexed: 11/25/2022]
Abstract
PURPOSE The activation of the renin-angiotensin-aldosterone system caused by renal ischaemia in atherosclerotic renal artery stenosis (ARAS) may be responsible for serious cardiovascular and renal consequences. The aim of the study was to assess the long-term safety, tolerability and outcomes of the use of angiotensin I-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) in patients with ARAS. METHODS Thirty-six patients with angiographically defined ARAS (managed either with revascularization or only with medical treatment) were prospectively assessed for the safety, tolerability and outcomes of the use of ACEis or ARBs. RESULTS The mean period of follow-up was 88.9 ± 37.8 months. A statistically significant reduction in systolic and diastolic blood pressure was recorded over time (P < 0.001). While estimated glomerular filtration rate remained almost stable during the study period (0.816), nuclear EDTA-GFR showed a significant reduction over time (P = 0.03). Mean time from diagnosis/intervention to end-stage renal disease for the cohort of 36 patients was 165.38 ± 13.62 months. Mean overall patient survival was 135.36 ± 15.25 months, with fourteen deaths (38.8%) occurring during the observational period. ACEi/ARB therapy was discontinued transiently in only 4 subjects. CONCLUSIONS The use of ACEis/ARBs is safe and effective in patients with ARAS independently of any parameters.
Collapse
Affiliation(s)
- Sofia Sofroniadou
- Department of Renal Medicine and Transplantation, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners AHSC, London, SE1 9RT, UK
| | | | | | | | | |
Collapse
|
50
|
Balzer KM, Neuschäfer S, Sagban TA, Grotemeyer D, Pfeiffer T, Rump LC, Sandmann W. Renal artery revascularization after unsuccessful percutaneous therapy: a single centre experience. Langenbecks Arch Surg 2011; 397:111-5. [DOI: 10.1007/s00423-011-0857-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Accepted: 09/29/2011] [Indexed: 10/16/2022]
|