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Abstract
Severe renal artery stenosis may cause renovascular hypertension; in case of bilateral narrowing or in a stenotic solitary or transplant kidney, renal insufficiency (ischemic renal disease) or rarely pulmonary flash edema may occur. In most cases arteriosclerotic disease is the underlying cause; less prevalent are the various manifestations of fibromuscular disease. Renal artery stenosis may be treated by revasularization, using either percutaneous (balloon angioplasty, stenting) or rarely open surgical procedures, both with excellent primary patency rates. However, randomized trials of renal artery angioplasty or stenting in patients with arteriosclerotic lesions have failed to demonstrate a longer-term benefit with regard to hypertension control and renal dysfunction over medical management alone. Careful patient selection is essential to maximize the potential benefit (e.g., in patients with refractory hypertension, progressive renal failure or recurrent pulmonary flash edema).
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Affiliation(s)
- T Lenz
- KfH-Nierenzentrum, Maxstr. 48, 67059, Ludwigshafen, Deutschland,
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2
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Kiss I, Ambrus C, Kulcsár I, Szegedi J, Kerkovits L, Tislér A, Kiss Z. Interaction between angiotensin-converting enzyme gene insertion/deletion polymorphism and angiotensin-converting enzyme inhibition on survival in hemodialyzed patients. Medicine (Baltimore) 2014; 93:e315. [PMID: 25526485 PMCID: PMC4603087 DOI: 10.1097/md.0000000000000315] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The association between ACE (angiotensin-converting enzyme) gene insertion/deletion (I/D) polymorphism and mortality has been inconsistently observed in earlier studies in patients on maintenance hemodialysis. We hypothesized that the effect of ACE gene I/D polymorphism on mortality may be influenced by concurrent ACE inhibitor therapy in this population. In this prospective, multicenter cohort, observational study, data was collected from 716 prevalent chronic hemodialysis patients, blood samples were genotyped for I/D single nucleotide polymorphism. Patient mortality was assessed in tree genotype groups insertion/insertion, insertion/deletion and deletion/deletion (I/I, I/D, and D/D) using multivariate Cox proportional hazard models. The most frequent genotype was I/D (42.6%), followed by D/D (37.7%) and I/I (19.7%) genotypes. The mean age was 54.9±15.5 years, 53.2% of all patients were male and in the total group the prevalence of diabetes was 19.3%. ACE inhibitor therapy was prescribed for 47.9% of all patients. The median duration of dialysis before blood sampling was 23.8 months (IQR 11.2-47.1). Patients were followed for 10 years, the median follow-up time was 29.8 months (IQR 12.6-63.4). Patient characteristics were well balanced among the genotype groups. D/D genotype, was associated with inferior survival (I/I vs D/D: log-rank test: P=0.04) in patients not receiving ACE inhibitor therapy, and the presence of this therapy diminished this difference. There was no difference in survival among unselected patients with different genotypes. In multivariate Cox regression models, D/D genotype (compared to I/I) was a significant predictor of mortality only in patients without ACE inhibitor therapy (HR 0.67, 95% CI 0.46-0.97, P=0.03). Our data suggests that hemodialyzed patients with the deletion/deletion (D/D) genotype might have inferior outcome, and ACE inhibitor therapy may be associated with improved survival in this subgroup.
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Affiliation(s)
- István Kiss
- From the B.Braun Avitum Hungary (BRAVHU) CPLC Dialysis Network (IK, CA, IKulcsár, JS, LK, BBAVHU-DIALGENE Workgroup); Department of Nephrology-Hypertension, St Imre University Teaching Hospital, Budapest (IK, CA, LK); Division Section of Geriatrics, 2nd Department of Internal Medicine, Semmelweis University Faculty of Medicine, Budapest (IK); School for Ph.D. Candidates of Aesculap Academy, Budapest (IKulcsár, ZK); and 1st Department of Internal Medicine, Semmelweis University Faculty of Medicine, Budapest, Hungary (AT)
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3
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Alves M, Souza e Silva NAD, Salis LHA, Pereira BDB, Godoy PH, Nascimento EMD, Oliveira JMF. Survival and predictive factors of lethality in hemodialysis: D/I polymorphism of the angiotensin I-converting enzyme and of the angiotensinogen M235T genes. Arq Bras Cardiol 2014; 103:209-19. [PMID: 25076182 PMCID: PMC4193068 DOI: 10.5935/abc.20140105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 03/27/2014] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND End-stage kidney disease patients continue to have markedly increased cardiovascular disease morbidity and mortality. Analysis of genetic factors connected with the renin-angiotensin system that influences the survival of the patients with end-stage kidney disease supports the ongoing search for improved outcomes. OBJECTIVE To assess survival and its association with the polymorphism of renin-angiotensin system genes: angiotensin I-converting enzyme insertion/deletion and angiotensinogen M235T in patients undergoing hemodialysis. METHODS Our study was designed to examine the role of renin-angiotensin system genes. It was an observational study. We analyzed 473 chronic hemodialysis patients in four dialysis units in the state of Rio de Janeiro. Survival rates were calculated by the Kaplan-Meier method and the differences between the curves were evaluated by Tarone-Ware, Peto-Prentice, and log rank tests. We also used logistic regression analysis and the multinomial model. A p value ≤ 0.05 was considered to be statistically significant. The local medical ethics committee gave their approval to this study. RESULTS The mean age of patients was 45.8 years old. The overall survival rate was 48% at 11 years. The major causes of death were cardiovascular diseases (34%) and infections (15%). Logistic regression analysis found statistical significance for the following variables: age (p = 0.000038), TT angiotensinogen (p = 0.08261), and family income greater than five times the minimum wage (p = 0.03089), the latter being a protective factor. CONCLUSIONS The survival of hemodialysis patients is likely to be influenced by the TT of the angiotensinogen M235T gene.
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Affiliation(s)
- Mauro Alves
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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Hackam DG, Spence JD, Garg AX, Textor SC. Role of Renin-Angiotensin System Blockade in Atherosclerotic Renal Artery Stenosis and Renovascular Hypertension. Hypertension 2007; 50:998-1003. [DOI: 10.1161/hypertensionaha.107.097345] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Daniel G. Hackam
- From the Divisions of Clinical Pharmacology (D.G.H.) and Nephrology (A.X.G.), University of Western Ontario, London, Ontario, Canada; Stroke Prevention and Atherosclerosis Research Centre (J.D.S.), London, Ontario, Canada; and the Division of Nephrology and Hypertension (S.C.T.), Mayo Clinic College of Medicine, Rochester, Minn
| | - J. David Spence
- From the Divisions of Clinical Pharmacology (D.G.H.) and Nephrology (A.X.G.), University of Western Ontario, London, Ontario, Canada; Stroke Prevention and Atherosclerosis Research Centre (J.D.S.), London, Ontario, Canada; and the Division of Nephrology and Hypertension (S.C.T.), Mayo Clinic College of Medicine, Rochester, Minn
| | - Amit X. Garg
- From the Divisions of Clinical Pharmacology (D.G.H.) and Nephrology (A.X.G.), University of Western Ontario, London, Ontario, Canada; Stroke Prevention and Atherosclerosis Research Centre (J.D.S.), London, Ontario, Canada; and the Division of Nephrology and Hypertension (S.C.T.), Mayo Clinic College of Medicine, Rochester, Minn
| | - Stephen C. Textor
- From the Divisions of Clinical Pharmacology (D.G.H.) and Nephrology (A.X.G.), University of Western Ontario, London, Ontario, Canada; Stroke Prevention and Atherosclerosis Research Centre (J.D.S.), London, Ontario, Canada; and the Division of Nephrology and Hypertension (S.C.T.), Mayo Clinic College of Medicine, Rochester, Minn
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Reis KA, Onal B, Gonen S, Arinsoy T, Erten Y, Ilgit E, Soylemezoglu O, Derici U, Guz G, Bali M, Sindel S. Angiotensinogen and Plasminogen Activator Inhibitor-1 Gene Polymorphism in Relation to Renovascular Disease. Cardiovasc Intervent Radiol 2005; 29:59-63. [PMID: 16228848 DOI: 10.1007/s00270-005-0072-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The present study was designed to evaluate angiotensinogen (AGT) M235T and plasminogen activator inhibitor-1 (PAI-1) (4G/5G) polymorphisims in relation to the occurrence of atherosclerotic renal artery stenosis (ARAS) and recurrent stenosis. In this study, 30 patients were enrolled after angiographic demonstration of ARAS; 100 healthy subjects for AGT polymorphism and 80 healthy subjects for PAI-1 polymorphism were considered the control group. The patients were followed for a mean 46.1 +/- 9.2 months. The patients had significantly higher frequencies of the MT genotype and the T allele than control group (chi(2) = 18.2, p < 0.001 and chi(2) = 11.5 p < 0.001). There were no significant differences in the PAI-1 genotype and allele findings when the data for all patients were compared with that for the controls (chi(2)= 2.45, p = 0.29 and chi(2) = 0.019, p = 0.89). There were no significant differences in the genotype and allele findings for the patients with and without restenosis (p > 0.05). The C-reactive protein (CRP) level was higher in the patients with restenosis than in the patients without restenosis (7.694 +/- 0.39 mg/L and 1.56 +/- 1.08 mg/L) (p = 0.001). Our results suggest that the M235T MT genotype and T allele might be associated with increased risk of atherosclerotic renal artery stenosis. The CRP level might be an independent predictor for recurrent stenosis.
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Affiliation(s)
- Kadriye Altok Reis
- Department of Nephrology, Gazi University Faculty of Medicine, Ankara, Turkey.
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Ozdemir FN, Basaran O, Ozdemir BH, Tutal E, Bilezikci B, Atac B, Haberal M. Angiotensin-Converting Enzyme and Endothelial Constitutive Nitric Oxide Synthase Polymorphisms in Turkish Renal Transplant Population and Possible Influence on Renal Artery Atherosclerosis and Graft Survival. Transplant Proc 2005; 37:2929-32. [PMID: 16213264 DOI: 10.1016/j.transproceed.2005.08.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Renal transplant recipients are prone to accelerated atherosclerosis secondary to immunosuppressants, which may decrease graft survival. We sought to analyze the effects on renal graft survival of atherosclerotic degeneration in the renal artery and the influence of angiotensin-converting enzyme (ACE) endothelial constitutive nitric oxide synthase (ecNOS) gene polymorphisms. METHODS AND PATIENTS Thirty three renal transplant recipients (25 men) of mean age 28.4 +/- 9.6 years, received organs from 11 living related donors and were followed for at least 36 months. Genotyping was performed for the insertion/deletion ACE (I/D), angiotensin (AGT) (M-->T, 235), angiotensine 1 receptor (A-->C, 1166), angiotensin 2-receptor (A-->G, 1223), and ecNOS (b-->a, intron4) gene polymorphisms. Renal artery biopsies were performed during transplantation surgery to analyze the presence of atherosclerosis. RESULTS Pathological examination indicated that 18 donor specimens and nine recipient specimens had atherosclerotic degeneration. Survival analysis (36 months) indicated that graft survival rates of recipients who had atherosclerosis in the renal artery and who received an organ from donors with an atherosclerotic renal artery were shorter than in their counterparts (P = .02, P = .04, respectively). Comparison of genetic variations of recipients revealed that CC/TC variation of AGT was higher in patients with atherosclerosis (81% vs 53%, P = .03). There was no significant difference between groups in means of other gene polymorphisms. CONCLUSION Renin-angiotensin system gene polymorphism analysis of patients in renal transplantation waiting list may provide information about allograft survival and posttransplant atherosclerotic degeneration at graft vasculature of young transplant recipients.
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Affiliation(s)
- F N Ozdemir
- Department of Nephrology, Baskent University Hospital, Ankara, Turkey
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Losito A, Errico R, Santirosi P, Lupattelli T, Scalera GB, Lupattelli L. Long-term follow-up of atherosclerotic renovascular disease. Beneficial effect of ACE inhibition. Nephrol Dial Transplant 2005; 20:1604-9. [PMID: 15870215 DOI: 10.1093/ndt/gfh865] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Patients with atherosclerotic renovascular disease (ARVD) are almost invariably treated by revascularization. However, the long-term outcomes of this approach on survival and progression to renal failure have not been investigated and have not been compared with that of a purely medical treatment. The aim of this observational study was to investigate factors affecting long-term (over 5 years) outcome, survival and renal function of patients with ARVD treated invasively or medically. METHODS ARVD was demonstrated angiographically in 195 patients who were consecutively enrolled into a follow-up study. Patient age was 65.6+/-11.2 years, serum creatinine was 1.74+/-1.22 mg/dl and renal artery lumen narrowing was 73.5+/-17.5%. A revascularization was performed in 136 patients, whereas 54 subjects having comparable characteristics were maintained on a medical treatment throughout the study; five patients were lost during follow-up. RESULTS The main follow-up was 54.4+/-40.4 months. The assessment of cardiovascular survival and renal survival at the end of follow-up revealed 46 cardiovascular deaths, 20 patients with end-stage renal disease (ESRD) and 41 patients with an increase in serum creatinine of over one-third. The multivariate analysis showed that renal revascularization did not affect mortality or renal survival compared with medical treatment. Revascularization produced slightly lower increases in serum creatinine and a better control of blood pressure. A longer survival was associated with the use of angiotensin-converting enzyme inhibitors (ACEIs) (P = 0.002) in both revascularized and medically treated patients. The only significant predictor of ESRD was an abnormal baseline serum creatinine. CONCLUSIONS On long-term follow-up, ARVD was associated with a poor prognosis due to a high cardiovascular mortality and a high rate of ESRD. In our non-randomized study, revascularization was not a major advantage over medical treatment in terms of mortality or renal survival. The use of ACEIs was associated with improved survival.
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Affiliation(s)
- Attilio Losito
- Unità Operativa Nefrologia e Dialisi, Policlinico Monteluce, Università di Perugia, Italy.
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What are the Clinical Success Rates of Renal Intervention? J Vasc Interv Radiol 2005. [DOI: 10.1016/s1051-0443(05)70085-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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van Onna M, Kroon AA, Houben AJHM, Koster D, Zeegers MPA, Henskens LHG, Plat AW, Stoffers HEJH, de Leeuw PW. Genetic Risk of Atherosclerotic Renal Artery Disease. Hypertension 2004; 44:448-53. [PMID: 15326089 DOI: 10.1161/01.hyp.0000141440.02210.da] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
It is largely unknown to what extent genetic abnormalities contribute to the development of atherosclerotic renal artery disease. Among the potential candidate genes, those of the renin-angiotensin system and the endothelial nitric oxide synthase (eNOS) rank high because of their importance in the atherosclerotic process. We investigated the association of polymorphisms in these genes (the angiotensinogen Met235Thr, the angiotensin-converting enzyme insertion/deletion, the angiotensin II type-1 receptor A1166C, and the eNOS Glu298Asp) with the presence or absence of atherosclerotic renovascular disease in 456 consecutive hypertensive patients referred for renal angiography on the suspicion of renovascular hypertension. Nondiseased normotensive (n=200) and hypertensive (n=154) patients from a family practice served as external controls. Renal artery disease was present in 30% of our angiography group. The Asp allele of the eNOS Glu298Asp polymorphism was associated with atherosclerotic renal artery stenosis with an odds ratio of 1.44 (95% confidence interval 1.00 to 2.09) versus hypertensives with angiographically proven patent arteries, of 1.89 (1.24 to 2.87) versus hypertensive family practice controls, and of 2.09 (1.29 to 3.38) versus normotensive family practice controls. However, this allele also differed significantly between patients with patent renal arteries and normotensive and hypertensive controls. No differences were found with respect to the other genetic polymorphisms. We hypothesize that the Asp allele of the Glu298Asp polymorphism may predispose to the development of atherosclerotic lesions but that renal artery involvement depends on other factors, also.
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Affiliation(s)
- Marieke van Onna
- Department of Internal Medicine, University Hospital Maastrichtand Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
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Sakka Y, Babazono T, Sato A, Ujihara N, Iwamoto Y. ACE gene polymorphism, left ventricular geometry, and mortality in diabetic patients with end-stage renal disease. Diabetes Res Clin Pract 2004; 64:41-9. [PMID: 15036826 DOI: 10.1016/j.diabres.2003.10.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2003] [Revised: 09/18/2003] [Accepted: 10/07/2003] [Indexed: 11/25/2022]
Abstract
The objectives of this study were to determine the association between angiotensin converting enzyme (ACE) gene polymorphism and left ventricular (LV) geometry, and to clarify independent effects of ACE genotype on mortality after commencing dialysis in diabetic patients with end-stage renal disease (ESRD). A total of 106 diabetic patients, 71 men and 35 women, 11 type 1 and 95 type 2 diabetic, 57 +/- 12 (mean +/- standard deviation (S.D.)) years of age, who started dialysis were studied. Patients with cardiac diseases and those treated with ACE inhibitors were excluded because of potential effects on LV performance. Echocardiographic examination was performed within +/-2 months of the start of dialysis. Relation between ACE genotype and LV mass index (LVMI) or relative wall thickness (RWT) at onset of dialysis, and impact of ACE genotype on survival after commencing dialysis were evaluated. There were no significant differences in LVMI or RWT in the three ACE genotype groups at onset of dialysis. However, mortality of patients with the ACE-DD genotype was significantly higher than patients with the DI and II genotypes (hazard ratio, 2.318; P=0.043), based on a survival analysis with a mean follow-up duration of 60 months. The higher mortality in patients with the DD genotype was confirmed to be independent of LV hypertrophy and increases in RWT. In diabetic patients with ESRD, ACE genotype has no association with LV mass or RWT at the start of dialysis, but does have an independent impact on patient survival thereafter.
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MESH Headings
- Creatinine/blood
- Diabetes Mellitus, Type 1/enzymology
- Diabetes Mellitus, Type 1/genetics
- Diabetes Mellitus, Type 1/mortality
- Diabetic Nephropathies/blood
- Diabetic Nephropathies/enzymology
- Diabetic Nephropathies/genetics
- Diabetic Nephropathies/mortality
- Echocardiography
- Female
- Genotype
- Hematocrit
- Humans
- Kidney Failure, Chronic/blood
- Kidney Failure, Chronic/enzymology
- Kidney Failure, Chronic/genetics
- Kidney Failure, Chronic/mortality
- Male
- Middle Aged
- Peptidyl-Dipeptidase A/genetics
- Polymorphism, Genetic/genetics
- Sex Characteristics
- Survival Analysis
- Ventricular Dysfunction, Left/epidemiology
- Ventricular Function, Left/physiology
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Affiliation(s)
- Yumiko Sakka
- Division of Nephrology and Hypertension, Diabetes Center, Tokyo Women's Medical University School of Medicine, 8-1 Kawadacho, Shinjukuku, Tokyo 162-8666, Japan
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Ozdemir FN, Miçozkadioğlu H, Ataç FB, Verdi H, Colak T, Ozdemir BH, Arat Z, Sezer S, Haberal M. The renin-angiotensin system and endothelial nitric oxide synthase gene polymorphisms and cyclosporine toxicity in renal transplant patients. Transplant Proc 2004; 36:128-30. [PMID: 15013322 DOI: 10.1016/j.transproceed.2003.11.071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Although cyclosporine has improved graft survival, the toxicity of the drug frequently causes problem for renal transplant patients. Cyclosporine displays deleterious effects due to direct toxicity to the nephrons and vasoconstriction of afferent arterioles, effects that may be due to increased angiotensin II and decreased nitric oxide activity. We sought to examine the relation between cyclosporine toxicity and the RAS (angiotensin-converting enzyme, angiotesinogen, angiotensin 1 and 2 receptors, and ecNOS) gene polymorphisms in 111 renal transplant patients. Retrospectively, we correlated the results of graft biopsies from these 111 patients, with the cumulative drug doses (mg), mean blood levels (mg/mL), mean daily doses (mg), and mean doses (mg/kg/d) of cyclosporine. Overall 125 patients (38 women, 87 men) were enrolled in the study. Their mean age was 34.47 +/- 11.04 years. Twenty patients displayed cyclosporine toxicity on graft biopsy; 91 showed no evidence of the disorder. We could not find any relation between cyclosporine toxicity and gene polymorphisms (P >.05), although the mean mg/kg/d dose was significantly high among cyclosporine toxicity group (P =.028, RR = 1.42). In recent studies angiotensin II and nitric oxide have been suggested to be related to cyclosporine toxicity; however, our results failed to reveal an association between cyclosporine toxicity and angiotensin II or nitric oxide-related gene polymorphisms.
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Affiliation(s)
- F N Ozdemir
- Department of Nephrology, Başkent University School of Medicine, Ankara, Turkey.
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12
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Pizzolo F, Mansueto G, Minniti S, Mazzi M, Trabetti E, Girelli D, Corrocher R, Olivieri O. Renovascular disease: effect of ACE gene deletion polymorphism and endovascular revascularization. J Vasc Surg 2004; 39:140-7. [PMID: 14718831 DOI: 10.1016/s0741-5214(03)01018-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Renal artery stenosis (RAS) is associated with high cardiovascular mortality and significant clinical complications, including resistant hypertension and ischemic nephropathy. Despite availability of endovascular revascularization techniques, determining which patients should undergo revascularization and the timing of the procedure still are controversial. Several studies have reported a higher frequency of the DD genotype of the insertion/deletion (I/D) polymorphism of the angiotensin converting enzyme (ACE) gene in patients with RAS, and one study found higher mortality in patients with the DD genotype. Material and methods We retrospectively studied 100 patients with documented atherosclerotic RAS and evaluated long-term (median follow-up, 28 months) mortality, blood pressure control, and renal function in relation to the ACE genotype and two therapeutic strategies, that is, endovascular treatment with percutaneous renal transluminal angioplasty or stenting (ET group) versus conservative drug therapy (CT group). RESULTS Comparison between therapeutic groups showed a higher cumulative probability of survival (86.7% vs 67.1%), better blood pressure control (57.4% vs 29%), and slower decline in renal function (17.9% vs 48.4%) in the ET group. The DD genotype was strongly represented in our study patients (DD, 50%; II, 15.5%; I/D, 34.5%), but bore no relation to mortality, blood pressure control, decline in renal function, or rate of recurrent stenosis. CONCLUSIONS Conservative medical treatment of RAS, compared with endovascular treatment, is associated with higher mortality, poorer blood pressure control, and impaired renal function over the long term. Early endovascular treatment enables amelioration of this unfavorable evolution. The DD genotype does not predict clinical outcome of RAS.
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Affiliation(s)
- Francesca Pizzolo
- Section of Internal Medicine, Department of Clinical and Experimental Medicine, University of Verona, Policlinico Borgo Roma, 37134 Verona, Italy
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Frederiksen H, Gaist D, Bathum L, Andersen K, McGue M, Vaupel JW, Christensen K. Angiotensin I-converting enzyme (ACE) gene polymorphism in relation to physical performance, cognition and survival--a follow-up study of elderly Danish twins. Ann Epidemiol 2003; 13:57-65. [PMID: 12547486 DOI: 10.1016/s1047-2797(02)00254-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE Studies of younger individuals have suggested an association between ACE genotype and physical and cognitive performance. Using a longitudinal study of elderly twins we studied the association between ACE genotype and physical and cognitive functioning and survival in old age. METHODS Participants were 684 twins aged 73+ years from the 1997 and 1999 surveys of the Longitudinal Study of Aging Danish Twins. Cognitive skills were assessed by the MMSE, while physical abilities were determined through self-report in 1997 and through both self-report and measurement of performance in two physical tasks in 1999. Survival status was obtained through linkage with a national death register. RESULTS Neither physical nor cognitive performance was associated with ACE genotype at baseline in 1997, or at follow-up in 1999. For participants in both surveys longitudinal changes in these skills did not depend on ACE genotype. The relative risk of dying was increased in II compared with the DI and DD genotype with relative risks of 1.6 (95 percent confidence intervals 1.1-2.5) and 1.3 (0.8-2.1), respectively. CONCLUSION We found no substantial effects of ACE genotype on physical and cognitive performance, or rate of change among elderly. Persons with the D allele may have a lower mortality at older ages.
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Affiliation(s)
- Henrik Frederiksen
- Department of Epidemiology, Institute of Public Health, University of Southern Denmark, Main Campus: Odense University, Odense, Denmark
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Rundback JH, Murphy TP, Cooper C, Weintraub JL. Chronic renal ischemia: pathophysiologic mechanisms of cardiovascular and renal disease. J Vasc Interv Radiol 2002; 13:1085-92. [PMID: 12427806 DOI: 10.1016/s1051-0443(07)61948-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Chronic renal ischemia caused by renal artery stenosis (RAS) elicits a complex biologic response. Although the traditional pathophysiologic pathways underlying renal ischemia have been well studied, there is emerging evidence that additional mechanisms may be responsible for producing many of the hemodynamic alterations and end-organ injury seen in patients with RAS, including persistent hypertension, renal insufficiency, and cardiac disturbance syndromes. A better understanding of these mechanisms may allow earlier identification of RAS, provide markers to predict the response to revascularization, or allow unique therapeutic targets for drug development. This and a subsequent article will explore the pathophysiologic and clinical implications of chronic renal ischemia.
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Affiliation(s)
- John H Rundback
- Department of Radiology, New York Presbyterian Hospital/Columbia University Medical Center, New York, New York 10031, USA.
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Abstract
Ischemic nephropathy is a major cause of chronic renal failure in people over 50 years of age. In addition, renal artery stenosis is associated with increased mortality, particularly if renal or cardiac function is compromised. The diagnosis is made both by clinical characteristics and imaging studies. At present, duplex Doppler ultrasound and magnetic resonance angiography appear to be the most promising non-invasive screening tests. Although data from controlled trials are lacking, revascularization is the mainstay of therapy for ischemic nephropathy. Advances in percutaneous interventions now allow revascularization to be offered to many patients, including those who are poor surgical candidates. The role of medical therapies (statins, angiotensin-converting enzyme inhibitors, intensive control of blood pressure) and how to best utilize revascularization (which patients and when) remain to be defined.
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Affiliation(s)
- K R Tuttle
- The Heart Institute of Spokane, Spokane, Washington 99204-2340, USA.
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16
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Plouin PF, Guéry B, La Batide Alanore A. Atherosclerotic renal artery stenosis: surgery, percutaneous transluminal angioplasty, or medical therapy? Curr Hypertens Rep 2000; 2:482-9. [PMID: 10995525 DOI: 10.1007/s11906-000-0032-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Atherosclerotic renal artery stenosis typically occurs in high-risk patients with coexistent vascular disease elsewhere. Patients with atherosclerotic renal artery stenosis may develop progressive renal failure but have a much higher risk of dying of stroke or myocardial infarction than of progressing to endstage renal disease. Recent controlled trials comparing medication to revascularization have shown that only a minority of such patients can expect hypertension cure, whereas trials designed to document the ability of revascularization to prevent progressive renal failure are not yet available. Revascularization should be undertaken in patients with atherosclerotic renal artery stenosis and resistant hypertension or heart failure, and probably in those with rapidly deteriorating renal function or an increase in plasma creatinine levels during angiotensin converting enzyme inhibition. With or without revascularization, medical therapy using antihypertensive agents, statins, and aspirin is necessary in almost all cases.
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Affiliation(s)
- P F Plouin
- Service d'hypertension, Hôpital Européen Georges Pompidou (HEGP), 20 rue Leblanc, 75908 Paris Cedex 15, France
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