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Homorodean C, Ober MC, Spinu M, Olinic M, Tataru DA, Onea HL, Achim A, Lazar LF, Homorodean R, Deak B, Olinic DM. Outcomes after stenting of renal artery stenosis in patients with high-risk clinical features. Egypt Heart J 2024; 76:4. [PMID: 38236490 PMCID: PMC10796309 DOI: 10.1186/s43044-024-00435-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/11/2024] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND In patients with renal artery stenosis, revascularization was seen as a mean to improve outcomes, but large studies failed to show significant benefit in general population. However, data on benefits of renal artery stenting in patients with high-risk features, such as rapidly declining renal function and cardiac destabilization syndromes, are limited, as they were excluded from trials. In this descriptive study, we aimed to evaluate short- and long-term outcomes in high-risk patients with renal artery stenosis, treated by angioplasty and stenting. We have retrospectively interrogated our local databases for renal artery percutaneous interventions; patients at high-risk (rapidly declining renal function; stable chronic renal failure and bilateral renal artery disease; severe hypertensive crisis) were selected for the current analysis. RESULTS Of 30 patients undergoing renal artery stenting, 18 patients were deemed "high-risk." On short term, good in-hospital control of hypertension and cardiac stabilization were obtained in all patients. Renal function improved significantly only in patients admitted with rapidly declining renal function, with significant creatinine level fall from median 3.98 mg/dL to 2.02 mg/dL, p = 0.023. However, for the whole group, creatinine change was non-significant (- 0.12 mg/dL, p = NS). On the long term, five patients (27.8%) ended-up on chronic hemodialysis and six patients died (33.3%) after a median of 20 months. No death occurred during the first year after the procedure. CONCLUSIONS Percutaneous procedures are feasible and safe in patients with high-risk renal artery stenosis, especially in those with rapidly declining renal function, probably saving some of them from the immediate need for renal replacement therapy, but long-term results are negatively influenced by the precarious general and cardio-vascular status of these patients and by the pre-existing significant renal parenchymal disease, non-related to the renal artery stenosis.
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Affiliation(s)
- Calin Homorodean
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
- Cluj County Emergency Clinical Hospital, 3-5, Clinicilor Street, 400006, Cluj-Napoca, Cluj, Romania
| | - Mihai Claudiu Ober
- Cluj County Emergency Clinical Hospital, 3-5, Clinicilor Street, 400006, Cluj-Napoca, Cluj, Romania.
| | - Mihail Spinu
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
- Cluj County Emergency Clinical Hospital, 3-5, Clinicilor Street, 400006, Cluj-Napoca, Cluj, Romania
| | - Maria Olinic
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
- Cluj County Emergency Clinical Hospital, 3-5, Clinicilor Street, 400006, Cluj-Napoca, Cluj, Romania
| | - Dan-Alexandru Tataru
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
- Cluj County Emergency Clinical Hospital, 3-5, Clinicilor Street, 400006, Cluj-Napoca, Cluj, Romania
| | - Horea Laurentiu Onea
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
| | - Alexandru Achim
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
| | - Leontin Florin Lazar
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
| | - Romana Homorodean
- Cluj County Emergency Clinical Hospital, 3-5, Clinicilor Street, 400006, Cluj-Napoca, Cluj, Romania
| | - Balasz Deak
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
| | - Dan Mircea Olinic
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
- Cluj County Emergency Clinical Hospital, 3-5, Clinicilor Street, 400006, Cluj-Napoca, Cluj, Romania
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2
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Seydoux C, Hemett OM, Périard D, Descombes E. Severe acute kidney injury in a patient with renal artery stenosis of a single-functioning kidney: A case report of rapid normalisation of the renal function after percutaneous transluminal angioplasty with stent placement. SAGE Open Med Case Rep 2023; 11:2050313X231209639. [PMID: 37941982 PMCID: PMC10629318 DOI: 10.1177/2050313x231209639] [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: 07/21/2023] [Accepted: 10/06/2023] [Indexed: 11/10/2023] Open
Abstract
Revascularisation of renal arterial stenosis in acute settings, such as uncontrolled arterial hypertension, flash pulmonary oedema and/or acute renal failure, has shown controversial results in observational and prospective studies. Current guidelines do not recommend revascularisation in the occurrence of renal failure as revascularisation and best medical treatment have shown similar long-term outcomes on renal function. We describe a case of acute degradation of the renal function (with oligo-anuria and a peak creatinine of 462 µmol/L) after the re-introduction of an angiotensin-II receptor blocker (irbesartan) in a 66-year-old Caucasian diabetic male patient with bilateral renal stenosis and a right-sided single-functioning kidney, with a rapid improvement of the renal function which normalized 5 days after percutaneous angioplasty and stenting of the right renal artery.
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Affiliation(s)
- Claire Seydoux
- Department of Internal Medicine, University and Hospital of Fribourg, Fribourg, Switzerland
| | - Ould Maouloud Hemett
- Service of Nephrology, University and Hospital of Fribourg, Fribourg, Switzerland
| | - Daniel Périard
- Service of Angiology, University and Hospital of Fribourg, Fribourg, Switzerland
| | - Eric Descombes
- Service of Nephrology, University and Hospital of Fribourg, Fribourg, Switzerland
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Kawano M, Suzuki K, Fujimura N, Endo A, Kato A, Fujii K, Komatsu M, Takahashi T, Ryuzaki M, Harada H. Ultra-Low-Dose Contrast Using Transluminal Renal Angioplasty: The ULTRA Study. Vasc Endovascular Surg 2022; 57:324-330. [PMID: 36509460 DOI: 10.1177/15385744221145867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although severe atherosclerotic renal artery stenosis (ARAS) is a predictor of future cardiovascular events, large trials have not shown the benefits of percutaneous transluminal renal angioplasty (PTRA). This study aimed to validate the safety and efficacy of PTRA using low-concentration digital subtraction angiography (LC-DSA) in patients with severe ARAS and advanced chronic kidney disease (CKD). MATERIALS AND METHODS This prospective study was conducted between August 2018 and October 2021. Eighteen patients with 20 lesions, CKD stage 3b or worse, and significant renal artery stenosis were included and underwent PTRA using ultra-low-dose contrast medium. The primary endpoint was a change in renal function based on serum creatinine (sCr) level. RESULTS The mean sCr level significantly improved from 3.34 ± 1.8 mg/dL pre-PTRA to 2.48 ± 1.19 mg/dL at 1 month post-PTRA (P = .02). The mean amount of contrast used was 8.3 ± 3.9 mL per vessel. More severe stenosis and rapid deterioration of renal function before treatment were associated with improved kidney function. No cardiovascular or renal complications such as stroke or contrast-induced nephropathy were observed during the 30-day period. CONCLUSIONS PTRA using an ultra-low-dose contrast medium is safe and provides acceptable results.
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Affiliation(s)
- Megumi Kawano
- Department of Cardiology, 38562Tokyo Saiseikai Central Hospital, Minato-ku, Japan
| | - Kenji Suzuki
- Department of Cardiology, 38562Tokyo Saiseikai Central Hospital, Minato-ku, Japan
| | - Naoki Fujimura
- Department of Vascular Surgery, 38562Tokyo Saiseikai Central Hospital, Minato-ku, Japan
| | - Ayaka Endo
- Department of Cardiology, 38562Tokyo Saiseikai Central Hospital, Minato-ku, Japan
| | - Ai Kato
- Department of Nephrology, 38562Tokyo Saiseikai Central Hospital, Minato-ku, Japan
| | - Kentaro Fujii
- Department of Nephrology, 38562Tokyo Saiseikai Central Hospital, Minato-ku, Japan
| | - Motoaki Komatsu
- Department of Nephrology, 38562Tokyo Saiseikai Central Hospital, Minato-ku, Japan
| | - Toshiyuki Takahashi
- Department of Cardiology, 38562Tokyo Saiseikai Central Hospital, Minato-ku, Japan
| | - Munekazu Ryuzaki
- Department of Nephrology, 38562Tokyo Saiseikai Central Hospital, Minato-ku, Japan
| | - Hirohisa Harada
- Department of Vascular Surgery, 38562Tokyo Saiseikai Central Hospital, Minato-ku, Japan
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4
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Artyszuk Ł, Symonides B, Gaciong Z, Cienszkowska K, Ludwiczak M, Wrzaszczyk M, Szmigielski CA. A new threshold for kidney asymmetry improves association with abnormal renal-aortic ratio for diagnosis of renal artery stenosis. Vasc Med 2022; 27:551-556. [PMID: 36190768 DOI: 10.1177/1358863x221118604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Renal artery stenosis (RAS) reflects more widespread atherosclerosis deposition and is associated with high morbidity and mortality. According to the guidelines, a discrepancy in the size of the kidneys of over 15 mm found in an ultrasound should initiate the RAS diagnostic algorithm. This study aims to find the optimal threshold for renal asymmetry that better reflects the frequency of a significantly abnormal renal-aortic ratio (RAR), justifying further RAS diagnostic workup, than the currently used cut-off of 15 mm difference in renal diameters. METHODS The analysis included 1175 patients (mean age: 52 years, IQR: 38-66, men/women: 597/578) who underwent Doppler ultrasonography screening of renal arteries with recorded kidney size and RAR calculation. Ultrasound features of RAS were defined as a RAR greater than 3.5 or signs of renal artery occlusion. Receiver operating characteristic (ROC) curves were created and analyzed for absolute differences in kidney size and abnormal RAR. We calculated the area under the curve (AUC) and optimal cut-off values for sensitivity and specificity analysis. RESULTS The final analysis included 169 patients with a significant difference in renal dimension. RAS features were met in 61 patients. According to ROC curve analysis, the optimal index of renal asymmetry was 12 mm. The sensitivity and specificity for this method were 82.0% and 83.3%, respectively, and AUC was 86.3%. CONCLUSION Changing the definition of a significant difference in kidney size from 15 mm to 12 mm increases sensitivity and specificity for abnormal RAR and this finding may accelerate the diagnosis of RAS.
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Affiliation(s)
- Łukasz Artyszuk
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Bartosz Symonides
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Zbigniew Gaciong
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Cienszkowska
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Marta Ludwiczak
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Maciej Wrzaszczyk
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Cezary A Szmigielski
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
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5
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Li P, Niu G, Yan Z, Zhang B, Yang M. Case Report: Endovascular Treatment of Chronic Atherosclerotic Renal Artery Total Occlusions with Failed Medical Therapy. Front Surg 2022; 9:843568. [PMID: 36329980 PMCID: PMC9622779 DOI: 10.3389/fsurg.2022.843568] [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: 01/05/2022] [Accepted: 04/07/2022] [Indexed: 11/05/2022] Open
Abstract
Background Current guidelines generally no longer support revascularization for chronic renal artery occlusive diseases because results from randomized controlled trials favor medical therapy over angioplasty. However, increasing reports indicate that patients with renal artery occlusion (RAO) can benefit from revascularization under certain circumstances. Case summary Here, we present a patient with renal artery stenosis (RAS) who does not have refractory hypertension or fit any clinical trial inclusion criteria by far. Medical therapy failed to prevent the progression of RAS in this patient, leading to total occlusion of his right renal artery. This patient had progressive renal insufficiency but recovered renal function after endovascular treatment. Conclusion This case demonstrates that angioplasty can be beneficial in selected RAO patients, especially those with residual renal function and collateral perfusion.
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6
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de Bhailis Á, Al-Chalabi S, Hagemann R, Ibrahim S, Hudson A, Lake E, Chysochou C, Green D, Kalra PA. Managing acute presentations of atheromatous renal artery stenosis. BMC Nephrol 2022; 23:210. [PMID: 35710381 PMCID: PMC9204977 DOI: 10.1186/s12882-022-02813-8] [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: 03/10/2022] [Accepted: 05/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Atherosclerotic renovascular disease (ARVD) often follows an asymptomatic chronic course which may be undetected for many years. However, there are certain critical acute presentations associated with ARVD and these require a high index of suspicion for underlying high-grade RAS (renal artery stenosis) to improve patient outcomes. These acute presentations, which include decompensated heart failure syndromes, accelerated hypertension, rapidly declining renal function, and acute kidney injury (AKI), are usually associated with bilateral high-grade RAS (> 70% stenosis), or high-grade RAS in a solitary functioning kidney in which case the contralateral kidney is supplied by a vessel demonstrating renal artery occlusion (RAO). These presentations are typically underrepresented in large, randomized control trials which to date have been largely negative in terms of the conferred benefit of revascularization. CASE PRESENTATION Here we describe 9 individual patients with 3 classical presentations including accelerated phase hypertension, heart failure syndromes, AKI and a fourth category of patients who suffered recurrent presentations. We describe their response to renal revascularization. The predominant presentation was that consistent with ischaemic nephropathy all of whom had a positive outcome with revascularization. CONCLUSION A high index of suspicion is required for the diagnosis of RAS in these instances so that timely revascularization can be undertaken to restore or preserve renal function and reduce the incidence of hospital admissions for heart failure syndromes.
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Affiliation(s)
- Áine de Bhailis
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford, England.
| | - Saif Al-Chalabi
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford, England
| | - Rodrigo Hagemann
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford, England
| | - Sara Ibrahim
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford, England
| | - Amy Hudson
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford, England
| | - Edward Lake
- Department of Vascular Interventional Radiology, Manchester University NHS Foundation Trust, Manchester, England
| | - Constantina Chysochou
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford, England
| | - Darren Green
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford, England
| | - Philip A Kalra
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford, England
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7
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Yu MS, Xiang K, Haller ST, Cooper CJ. Renal Artery Interventions. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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8
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Nabil AA, Lesya K, Margarita K, Eliezer J. H, Uri R, Dganit D, Pazit B. Treatment of severe renal artery stenosis with acute kidney injury requiring hemodialysis by percutaneous transluminal renal angioplasty and stent implantation. J Vasc Interv Radiol 2022; 33:707-714.e2. [DOI: 10.1016/j.jvir.2022.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 01/29/2022] [Accepted: 03/01/2022] [Indexed: 11/26/2022] Open
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9
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Hicks CW, Clark TW, Cooper CJ, de Bhailís ÁM, De Carlo M, Green D, Małyszko J, Miglinas M, Textor SC, Herzog CA, Johansen KL, Reinecke H, Kalra PA. Atherosclerotic Renovascular Disease: A KDIGO (Kidney Disease: Improving Global Outcomes) Controversies Conference. Am J Kidney Dis 2022; 79:289-301. [PMID: 34384806 PMCID: PMC9834909 DOI: 10.1053/j.ajkd.2021.06.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 06/23/2021] [Indexed: 02/03/2023]
Abstract
The diagnosis and management of atherosclerotic renovascular disease (ARVD) is complex and controversial. Despite evidence from the ASTRAL (2009) and CORAL (2013) randomized controlled trials showing that percutaneous renal artery revascularization did not improve major outcomes compared with best medical therapy alone over 3-5 years, several areas of uncertainty remain. Medical therapy, including statin and antihypertensive medications, has evolved in recent years, and the use of renin-angiotensin-aldosterone system blockers is now considered the primary means to treat hypertension in the setting of ARVD. However, the criteria to identify kidneys with renal artery stenosis that have potentially salvageable function are evolving. There are also data suggesting that certain high-risk populations with specific clinical manifestations may benefit from revascularization. Here, we provide an overview of the epidemiology, diagnosis, and treatment of ARVD based on consensus recommendations from a panel of physician experts who attended the recent KDIGO (Kidney Disease: Improving Global Outcomes) Controversies Conference on central and peripheral arterial diseases in chronic kidney disease. Most focus is provided for contentious issues, and we also outline aspects of investigation and management of ARVD that require further research.
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10
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Salvage from hemodialysis via percutaneous transluminal renal artery stenting for a jeopardized solitary functioning kidney: A case report. J Cardiol Cases 2021; 24:268-271. [PMID: 34917207 DOI: 10.1016/j.jccase.2021.04.013] [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: 02/24/2021] [Revised: 04/17/2021] [Accepted: 04/25/2021] [Indexed: 11/20/2022] Open
Abstract
Atherosclerotic renal artery stenosis (ARAS) causes resistant hypertension, progressively declining renal function, and cardiac destabilization syndromes, including heart failure. We report a patient who underwent successful percutaneous transluminal renal angioplasty (PTRA) for anuretic acute kidney injury (AKI) due to ARAS. This patient, admitted to our hospital with congestive heart failure, developed anuretic AKI and started hemodialysis 3 days after admission. Computed tomography and magnetic resonance angiograms showed total occlusion of the proximal right renal artery, with atrophy of the right kidney and severe stenosis of the proximal left renal artery. These findings suggested that only the left kidney was functioning. We performed PTRA of the left renal artery in which the culprit lesion causing the AKI appeared to be located. Using intravascular ultrasound, severe calcification in the ostium of the left renal artery and a necrotic core with plaque rupture in the culprit lesion were observed. Kidney function recovered immediately after revascularization, which permitted successful withdrawal of hemodialysis. There is no clear consensus regarding the indication for PTRA in patients with ARAS; however, our experience suggests that PTRA may be beneficial for patients with a jeopardized solitary functioning kidney. <Learning objective: There is no clear consensus regarding the indication for percutaneous transluminal renal angioplasty (PTRA) in patients with atherosclerotic renal artery stenosis. However, patients with a jeopardized solitary functioning kidney may benefit from PTRA, which should be considered as soon as possible before irreversible ischemic changes occur. It is important to recognize that PTRA may be indicated in select similar cases.>.
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11
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Lestari S, Prasanto H, Kuswadi I. Renovascular Hypertension in Chronic Hemodialytic Patient. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.6741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Hypertension is a major contributor to the development of chronic kidney disease. Data in Indonesia, hypertension is still the most comorbid disease in CKD patients on dialysis (51%). Hypertension in CKD on dialysis patients is common and often uncontrolled. Renovascular hypertension is the most common cause of secondary hypertension. Diagnosis and treatment of RAS is very important, because it can accelerate the achievement of blood pressure targets, reduce the risk and complications due to hypertension.
Case Report: A 52-year-old woman with CKD has been undergoing hemodialysis for 2 years. Hypertension that was previously well controlled for 2 years required an increase in antihypertensive therapy from 2 to 4 drugs in recent months. On physical examination the blood pressure 180/90 mmHg, pulse 79 bpm, respiration 20/min, temperature 36.7oC. Conjunctiva looks anemic, cardiomegaly, lungs within normal limits, no ascites and edema in the extremities. On renal artery duplex ultrasound examination, right main renal artery acceleration time 147.65 ms, Peak Systolic Velocity (PSV) 31.9 cm/s. RI 0.69 and left main renal artery acceleration time 120.81 ms, PSV 16.9 cm/s, RI 0.61. There was 20-30% left renal artery stenosis, 80% right renal artery stenosis. A stent was placed on the right renal artery. The patient's condition after PTRA improved, but at the next follow-up, mean systole and diastole 170 mmHg and 80 mmHg, respectively. Patient received 4 antihypertensive therapy.
Conclusion: Renal artery stenosis is a disease that consists of a broad spectrum of different entities with different pathophysiologies that require varied approaches to diagnose and treat. Current diagnostic tools include MRA, CTA and renal artery duplex ultrasonography. Patients with renal parenchymal disease are poorer candidates for revascularization.
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12
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Takahashi W, Morita T, Tanaka K, Ide S, Hujimori K, Takahashi Y. Determinant role of renal artery stenting in recovery from acute worsening of atherosclerotic renal failure. J Cardiol Cases 2021; 24:49-51. [PMID: 34354776 PMCID: PMC8319614 DOI: 10.1016/j.jccase.2020.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 11/21/2020] [Accepted: 12/05/2020] [Indexed: 11/23/2022] Open
Abstract
Because previous randomized clinical trials have failed to show any benefits of renal artery stenting (RAS), clinicians have been confused regarding the optimal management of patients with atherosclerotic renal artery stenosis (ARAS). Here, we report a notable case with ARAS whose clinical course could help clinicians identify patients suitable for RAS. A 66-year-old woman with ARAS and some parameter abnormalities on renal duplex ultrasound was admitted to our hospital with severe hypertension (>250 mmHg). After the initiation of antihypertensive intravenous treatment, the patient manifested acute worsening of renal function over 6 days and required dialysis. Because renal failure continued to deteriorate over more than 4 weeks, we performed stenting to the severe ostial stenosis of the right renal artery. As a result, the patient achieved dramatic improvement in renal function and successful withdrawal from dialysis and has maintained stable control of blood pressure without additional events for more than 2 years since discharge. This case suggests that careful analysis of the patient's profile, such as history of rapidly deteriorating renal failure, presence of bilateral ARAS, or a solitary functional kidney, in addition to various parameters of renal duplex ultrasound, may help predict the efficacy of RAS in patients with ARAS. <Learning objective: Because several randomized studies have reported negative results for renal artery stenting (RAS), an individual-based approach is required for the treatment of atherosclerotic renal artery stenosis (ARAS). To determine whether RAS could be effective in patients with ARAS, it is important to assess patient-specific characteristics such as progression of renal failure (e.g. acute worsening), presence of bilateral ARAS, or the existence of a solitary functional kidney, as well as parameters of related examinations such as the renal arterial resistive index.>
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13
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Li L, Wang M, Li J, Guan X, Xin P, Wang X, Liu Y, Li H, Jiang W, Gong M, Zhang H. Short Term Prognosis of Renal Artery Stenosis Secondary to Acute Type B Aortic Dissection With TEVAR. Front Cardiovasc Med 2021; 8:658952. [PMID: 33969023 PMCID: PMC8102698 DOI: 10.3389/fcvm.2021.658952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/29/2021] [Indexed: 12/26/2022] Open
Abstract
Objective: To determine the effect of renal artery stenosis (RAS) resulting from acute type B aortic dissection (ATBAD) with thoracic endovascular aortic repair (TEVAR) on early prognosis in patients with ATBAD. Methods: A total of 129 ATBAD patients in the National Acute Aortic Syndrome Database (AASCN) who underwent TEVAR between 2019 and 2020 were enrolled in our study. Patients were divided into two groups: the RAS group and the non-RAS group. Results: There were 21 RAS patients (16.3%) and 108 non-RAS patients (83.7%) in our cohort. No patient in our cohort died during the 1-month follow-up. There was no significant difference in preoperative creatinine clearance rate (CCr) between the two groups (90.6 ± 46.1 μmol/L in the RAS group vs. 78.7 ± 39.2 μmol/L in the non-RAS group, P = 0.303) but the RAS group had a significantly lower estimated glomerular filtration rate (eGFR) than the non-RAS group (83.3 ± 25.0 vs. 101.9 ± 26.9 ml/min, respectively; P = 0.028).One month after TEVAR, CCr was significantly higher (99.0 ± 68.1 vs. 78.5 ± 25.8 ml/min, P = 0.043) and eGFR (81.7 ± 23.8 vs. 96.0 ± 20.0 ml/min, P = 0.017) was significantly lower in the RAS group than in the non-RAS group. Conclusions: In ATBAD, RAS could result in acute kidney injury (AKI) in the early stage after TEVAR. The RAS group had a high incidence of hypertension. These results suggest that patients with RAS may need further treatment.
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Affiliation(s)
- Lei Li
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
| | - Maozhou Wang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
| | - Jinzhang Li
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
| | - Xinliang Guan
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
| | - Pu Xin
- Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing, China.,Department of Medical Imaging, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaolong Wang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
| | - Yuyong Liu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
| | - Haiyang Li
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
| | - Wenjian Jiang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
| | - Ming Gong
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
| | - Hongjia Zhang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing, China.,Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
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14
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Chen Y, Pan H, Luo G, Li P, Dai X. Use of percutaneous transluminal renal angioplasty in atherosclerotic renal artery stenosis: a systematic review and meta-analysis. J Int Med Res 2021; 49:300060520983585. [PMID: 33478308 PMCID: PMC7841243 DOI: 10.1177/0300060520983585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/30/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE For patients with atherosclerotic renal artery stenosis (ARAS), the role of percutaneous transluminal renal angioplasty (PTRA) remains inconclusive. This study aimed to comparatively evaluate the benefits of best medical therapy (BMT) plus PTRA and BMT alone in treating ARAS. METHODS We performed a systematic review and meta-analysis, and searched for all randomized, controlled trials that reported patients with ARAS. The effectiveness and safety in the BMT plus PTRA and BMT alone groups were estimated, taking into account hypertension, stroke, renal events, cardiac events, and mortality. RESULTS Nine randomized, controlled trials involving 2309 patients were included. In the BMT plus PTRA group, the incidence of refractory hypertension was significantly lower compared with that in the BMT alone group (odds ratio 0.09; 95% confidence interval 0.01, 0.70). However, there were no significant differences in the rates of stroke, renal events, cardiac events, cardiac mortality, and all-cause mortality between the two groups. CONCLUSIONS PTRA plus BMT improves blood pressure in patients with ARAS, but there is insufficient evidence for this therapy in improving stroke, renal events, cardiac events, and cardiac and all-cause mortality.
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Affiliation(s)
- Yonghui Chen
- Vascular Surgery Department, Tianjin Medical
University General Hospital, Tianjin, China
| | - Hongrui Pan
- Vascular Surgery Department, Tianjin Medical
University General Hospital, Tianjin, China
| | - Guangze Luo
- Vascular Surgery Department, Tianjin Medical
University General Hospital, Tianjin, China
| | - Peng Li
- Vascular Surgery Department, Tianjin Medical
University General Hospital, Tianjin, China
| | - Xiangchen Dai
- Vascular Surgery Department, Tianjin Medical
University General Hospital, Tianjin, China
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15
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How should we define appropriate patients for percutaneous transluminal renal angioplasty treatment? Hypertens Res 2020; 43:1015-1027. [PMID: 32572170 DOI: 10.1038/s41440-020-0496-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 05/28/2020] [Accepted: 05/28/2020] [Indexed: 01/15/2023]
Abstract
Renovascular hypertension (RVH) is one of the most common causes of secondary hypertension and can result in resistant hypertension. RVH is associated with an increased risk for progressive decline in renal function, cardiac destabilization syndromes including "flash" pulmonary edema, recurrent congestive heart failure, and cerebrocardiovascular disease. The most common cause of renal artery stenosis (RAS) is atherosclerotic lesions, followed by fibromuscular dysplasia. The endovascular technique of percutaneous transluminal renal angioplasty (PTRA) with or without stenting is one of the standard treatments for RAS. Randomized controlled trials comparing medical therapy with PTRA to medical therapy alone have failed to show a benefit of PTRA; however, the subjects of these randomized clinical trials were limited to atherosclerotic RAS patients, and patients with the most severe RAS, who would be more likely to benefit from PTRA, might not have been enrolled in these trials. This review compares international guidelines related to PTRA, reevaluates the effects of PTRA treatment on blood pressure and renal and cardiac function, discusses strategies for the management of RVH patients, and identifies factors that may predict which patients are most likely to benefit from PTRA.
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16
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Prince M, Tafur JD, White CJ. When and How Should We Revascularize Patients With Atherosclerotic Renal Artery Stenosis? JACC Cardiovasc Interv 2020; 12:505-517. [PMID: 30898248 DOI: 10.1016/j.jcin.2018.10.023] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/19/2018] [Accepted: 10/01/2018] [Indexed: 01/21/2023]
Abstract
Atherosclerotic renal artery stenosis is the leading cause of secondary hypertension and may lead to resistant (refractory) hypertension, progressive decline in renal function, and cardiac destabilization syndromes (pulmonary edema, recurrent heart failure, or acute coronary syndromes) despite guideline-directed medical therapy. Although randomized controlled trials comparing medical therapy with medical therapy and renal artery stenting have failed to show a benefit for renal artery stenting, according to comparative effectiveness reviews by the Agency for Healthcare Research and Quality, the trials may not have enrolled patients with the most severe atherosclerotic renal artery stenosis, who would be more likely to benefit from renal stenting. Because of limitations of conventional angiography, it is critical that the hemodynamic severity of moderately severe (50% to 70%) atherosclerotic renal artery stenosis lesions be confirmed on hemodynamic measurement. The authors review techniques to optimize patient selection, to minimize procedural complications, and to facilitate durable patency of renal stenting. The authors also review the current American College of Cardiology and American Heart Association guidelines and the Society for Cardiovascular Angiography and Interventions appropriate use criteria as they relate to renal stenting.
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Affiliation(s)
- Marloe Prince
- Department of Cardiology at Ochsner Clinic Foundation, New Orleans, Louisiana.
| | - Jose D Tafur
- Department of Cardiology at Ochsner Clinic Foundation, New Orleans, Louisiana
| | - Christopher J White
- Department of Cardiology at Ochsner Clinic Foundation, New Orleans, Louisiana
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17
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Mishima E, Suzuki T, Ito S. Selection of Patients for Angioplasty for Treatment of Atherosclerotic Renovascular Disease: Predicting Responsive Patients. Am J Hypertens 2020; 33:391-401. [PMID: 31996895 DOI: 10.1093/ajh/hpaa016] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/24/2020] [Accepted: 01/27/2020] [Indexed: 01/22/2023] Open
Abstract
Atherosclerotic renal artery stenosis (ARAS) can cause secondary hypertension, progressive decline in renal function, and cardiac complications. Recent randomized controlled trials including the Cardiovascular Outcomes in Renal Atherosclerotic Lesions study have not reported the benefit of renal artery stenting compared with medical therapy alone to improve renal function or reduce cardiovascular and renal events in the enrolled patients with ARAS. However, observational evidence indicating the benefits of angioplasty in the selected high-risk patients with ARAS has been increasing. Thus, the timely correction of stenosis through angioplasty may have a beneficial effect in selected patients. However, optimal patient selection for angioplasty has been debated and can be challenging at times. Clinicians must identify the responsive patients who would benefit from angioplasty through risk stratification and the prediction of outcomes. Efforts have been made for the determination of predictors that can identify the subgroups of patients who would benefit from angioplasty. Lower age, more severe stenosis, preserved renal perfusion, and absence of diabetes or generalized atherosclerosis have been reported as the predictors for the improvement of hypertension after angioplasty. Global renal ischemia, rapidly declining renal function over 6-12 months, progressive shrinkage of the affected kidney, lower resistive index, and lower levels of albuminuria have been reported as predictors of improved or preserved renal function after angioplasty. This review discusses the identification of ARAS patients who will potentially respond well to angioplasty.
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Affiliation(s)
- Eikan Mishima
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takehiro Suzuki
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Sadayoshi Ito
- Department of Medicine, Katta General Hospital, Shiroishi, Japan
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18
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Simeoni M, Borrelli S, Garofalo C, Fuiano G, Esposito C, Comi A, Provenzano M. Atherosclerotic-nephropathy: an updated narrative review. J Nephrol 2020; 34:125-136. [PMID: 32270411 DOI: 10.1007/s40620-020-00733-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 04/03/2020] [Indexed: 12/13/2022]
Abstract
The increased prevalence of chronic kidney disease (CKD) in elderly patients recognizes, as main cause, the long-term exposure to atherosclerosis and hypertension. Chronic ischemic damage due to critical renal arterial stenosis induces oxidative stress and intra-renal inflammation, resulting in fibrosis and microvascular remodelling, that is the histological picture of atherosclerotic renal vascular disease (ARVD). The concomitant presence of a long history of hypertension may generate intimal thickening and luminal narrowing of renal arteries and arterioles, glomerulosclerosis, interstitial fibrosis and tubular atrophy, more typically expression of hypertensive nephropathy. These complex mechanisms contribute to the development of CKD and the progression to End Stage Kidney Disease. In elderly CKD patients, the distinction among these nephropathies may be problematic; therefore, ischemic and hypertensive nephropathies can be joined in a unique clinical syndrome defined as atherosclerotic nephropathy. The availability of novel diagnostic procedures, such as intra-vascular ultrasound and BOLD-MRI, in addition to traditional imaging, have opened new scenarios, because these tools allow to identify ischemic lesions responsive to renal revascularization. Indeed, although trials have deflated the role of renal revascularization on the renal outcomes, it should be still used to avoid dialysis initiation and/or to reduce blood pressure in selected elderly patients at high risk. Nonetheless, lifestyle modifications (smoking cessation, increased physical activity), statins and antiplatelet use, as well as cautious use of renin-angiotensin system inhibitors, remain the main therapeutic approach aimed at slowing the renal damage progression. Mesenchymal stem cells and Micro-RNA are promising target of anti-fibrotic therapy, which might provide potential benefit in ARVD patients, though safety and efficacy profile in humans is unknown too.
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Affiliation(s)
| | - Silvio Borrelli
- Nephrology and Dialysis Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Carlo Garofalo
- Nephrology and Dialysis Unit, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Giorgio Fuiano
- Nephrology Units at University "Magna Graecia", Catanzaro, Italy
| | | | - Alessandro Comi
- Nephrology Units at University "Magna Graecia", Catanzaro, Italy
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19
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Abstract
Atherosclerotic renal artery stenosis is the most common cause of secondary hypertension and may cause progressive renal disease and cardiac destabilization syndromes. Guideline-directed medical therapy is advised in all patients. Patients with refractory symptoms and hemodynamically significant stenoses are more likely to benefit from renal artery stent placement. Chronic mesenteric ischemia (CMI) is an infrequent and difficult to diagnose illness. Due to robust collateralization, clinical symptoms from mesenteric artery stenosis or occlusion is uncommon. Atherosclerosis is the most common etiology of CMI. Current evidence suggests that, compared with open surgical repair, endovascular therapy is the most cost-effective choice for CMI.
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Affiliation(s)
- Tamunoinemi Bob-Manuel
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Center, Ochsner Medical Center, The Ochsner Clinical School, University of Queensland, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| | - Christopher J White
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Center, Ochsner Medical Center, The Ochsner Clinical School, University of Queensland, 1514 Jefferson Highway, New Orleans, LA 70121, USA; Department of Cardiology, Ochsner Medical Center, 3rd Floor, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
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20
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Boutari C, Georgianou E, Sachinidis A, Katsimardou A, Christou K, Piperidou A, Karagiannis A. Renovascular Hypertension: Novel Insights. Curr Hypertens Rev 2020; 16:24-29. [DOI: 10.2174/1573402115666190416153321] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 03/31/2019] [Accepted: 04/01/2019] [Indexed: 11/22/2022]
Abstract
Renovascular hypertension (RVH) remains among the most prevalent and important, but
also potentially reversible, causes of secondary hypertension. The predominant causes of renal artery
stenosis (RAS) are atherosclerotic renovascular arterial stenosis (ARAS) and renal fibromuscular
dysplasia. This condition can lead to progressive renal injury, cardiovascular complications and
‘flash pulmonary edema’. Duplex Doppler ultrasonography, computed tomographic angiography
and magnetic resonance angiography are the most commonly used diagnostic methods. There are
three therapeutic options available: medical therapy including renin-angiotensin-aldosterone system
antagonists, lipid-lowering agents, and antiplatelet therapy, percutaneous angioplasty with or without
stent placement and surgical revascularization. Three large trials failed to demonstrate the superiority
of renal artery revascularization over pharmaceutical therapy in controlling blood pressure
and preserving renal function. For this reason, today revascularization is only recommended for
patients with progressive worsening of renal function, recurrent ‘flash pulmonary edema’ and rapid
increase in antihypertensive requirement in patients with previously well-controlled hypertension.
However, more properly designed trials are needed in order to identify which patient populations
would probably benefit from renal revascularization.
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Affiliation(s)
- Chrysoula Boutari
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, 49 Konstantinoupoleos, Thessaloniki, 54642, Greece
| | - Eleni Georgianou
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, 49 Konstantinoupoleos, Thessaloniki, 54642, Greece
| | - Alexandros Sachinidis
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, 49 Konstantinoupoleos, Thessaloniki, 54642, Greece
| | - Alexandra Katsimardou
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, 49 Konstantinoupoleos, Thessaloniki, 54642, Greece
| | - Konstantinos Christou
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, 49 Konstantinoupoleos, Thessaloniki, 54642, Greece
| | - Alexia Piperidou
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, 49 Konstantinoupoleos, Thessaloniki, 54642, Greece
| | - Asterios Karagiannis
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, 49 Konstantinoupoleos, Thessaloniki, 54642, Greece
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21
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Cooper EL, Xie Y, Nguyen H, Brewster PS, Sholl H, Sharrett M, Ren K, Chen T, Tuttle KR, Haller ST, Jamerson K, Murphy TP, D'Agostino RB, Massaro JM, Henrich W, Cooper CJ, Cutlip DE, Dworkin LD, Shapiro JI. Early Rapid Decline in Kidney Function in Medically Managed Patients With Atherosclerotic Renal Artery Stenosis. J Am Heart Assoc 2019; 8:e012366. [PMID: 31433717 PMCID: PMC6585374 DOI: 10.1161/jaha.119.012366] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background Early rapid declines of kidney function may occur in patients with atherosclerotic renal artery stenosis with institution of medical therapy. The causes and consequences are not well understood. Methods and Results Patients enrolled in the medical therapy–only arm of the CORAL (Cardiovascular Outcomes With Renal Artery Lesions) study were assessed for a rapid decline (RD) in estimated glomerular filtration rate (eGFR), defined as a ≥30% decrease from baseline to either 3 months, 6 months, or both. In the medical therapy–only cohort, eGFR was available in 359 subjects at all time points, the subjects were followed for a median of 4.72 years, and 66 of 359 (18%) subjects experienced an early RD. Baseline log cystatin C (odds ratio, 1.78 [1.11–2.85]; P=0.02), age (odds ratio, 1.04 [1.00–1.07]; P<0.05), and Chronic Kidney Disease Epidemiology Collaboration creatinine eGFR (odds ratio, 1.86 [1.15–3.0]; P=0.01) were associated with an early RD. Despite continued medical therapy only, the RD group had an improvement in eGFR at 1 year (6.9%; P=0.04). The RD and nondecline groups were not significantly different for clinical events and all‐cause mortality (P=0.78 and P=0.76, respectively). Similarly, renal replacement therapy occurred in 1 of 66 (1.5%) of the RD patients and in 6 of 294 (2%) of the nondecline patients. The regression to the mean of improvement in eGFR at 1 year in the RD group was estimated at 5.8±7.1%. Conclusions Early rapid declines in kidney function may occur in patients with renal artery stenosis when medical therapy is initiated, and their clinical outcomes are comparable to those without such a decline, when medical therapy only is continued. See Editorial Beige
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Affiliation(s)
- Emily L. Cooper
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Yanmei Xie
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Hanh Nguyen
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Pamela S. Brewster
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Haden Sholl
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Megan Sharrett
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Kaili Ren
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Tian Chen
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Katherine R. Tuttle
- Division of NephrologyUniversity of Washington School of MedicineProvidence Sacred Heart Medical CenterSpokaneWA
| | - Steven T. Haller
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | | | - Timothy P. Murphy
- Department of Diagnostic ImagingRhode Island Hospital and Alpert Medical School of Brown UniversityProvidenceRI
| | | | - Joseph M. Massaro
- Department of BiostatisticsSchool of Public HealthBoston UniversityBostonMA
| | | | - Christopher J. Cooper
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
| | - Donald E. Cutlip
- Department of MedicineHarvard UniversityBeth Israel Deaconess Medical CenterBostonMA
| | - Lance D. Dworkin
- Department of MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOH
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22
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Anty R, Favre G, Coilly A, Rossignol E, Houssel-Debry P, Duvoux C, De Ledinghen V, Di Martino V, Leroy V, Radenne S, Kamar N, Canva V, D'Alteroche L, Durand F, Dumortier J, Lebray P, Besch C, Tran A, Canivet CM, Botta-Fridlund D, Montialoux H, Moreno C, Conti F, Silvain C, Perré P, Habersetzer F, Abergel A, Debette-Gratien M, Dharancy S, Esnault VLM, Fougerou-Leurent C, Cagnot C, Diallo A, Veislinger A, Danjou H, Samuel D, Pageaux GP, Duclos-Vallée JC. Safety of sofosbuvir-based regimens after liver transplantation: longitudinal assessment of renal function in the prospective ANRS CO23 CUPILT study. Aliment Pharmacol Ther 2018; 47:1682-1689. [PMID: 29665081 DOI: 10.1111/apt.14639] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 01/09/2018] [Accepted: 03/07/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND In liver transplant recipients with hepatitis C virus recurrence, there is concern about renal safety of sofosbuvir-based regimens. Changes in serum creatinine or in the estimated glomerular filtration rate (eGFR) under treatment are used to look for possible renal toxicity. However, serum creatinine and eGFR are highly variable. AIM To analyse renal function trajectory with numerous assays of serum creatinine over a long period of time. METHODS In a multicentre cohort of 139 patients, the eGFR was obtained from serum creatinine using the Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equation. Slopes of eGFR were defined as a change in eGFR during a period divided by time. Pre-treatment, on-treatment and post-treatment periods were 9 months, 3-9 months and 4.5 months. Interactions between eGFR slopes and the pre-treatment eGFR, use of ribavirin or mycophenolate mofetil, and stage of fibrosis were addressed. On-treatment eGFR slopes were separated in tertiles. Pre- and post-treatment eGFR slopes were compared globally and according to tertiles. RESULTS The post-treatment eGFR slope was significantly better than pre-treatment eGFR slope (+0.18 (IQR -0.76 to +1.32) vs -0.11 (IQR -1.01 to +0.73) mL/min/1.73 m2 /month, P = 0.03) independently of the pre-treatment eGFR (P = 0.99), ribavirin administration (P = 0.26), mycophenolate mofetil administration (P = 0.51) and stage of fibrosis (F3 and F4 vs lower stages, P = 0.18; F4 vs lower stages, P = 0.08; F4 Child-Pugh B and C vs lower stages, P = 0.38). Tertiles of on-treatment eGFR slopes were -1.71 (IQR -2.54 to -1.48), -0.78 (IQR -1.03 to -0.36) and +0.75 (IQR +0.28 to +1.47) mL/min/1.73 m2 /month. Pre- and post-treatment eGFR slopes were not significantly different according to tertiles (respectively, P = 0.34, 0.08, 0.73). CONCLUSION The eGFR varies during treatment and gives a confusing picture of the renal safety of sofosbuvir-based regimens. In contrast, longitudinal assessment of the eGFR shows a rising trajectory over longer time, meaning that these therapies are safe for the kidneys in our cohort of liver transplant recipients.
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23
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Manohar S, Hamadah A, Herrmann SM, Textor SC. Total Renal Artery Occlusion: Recovery of Function After Revascularization. Am J Kidney Dis 2018; 71:748-753. [PMID: 29429749 PMCID: PMC5916323 DOI: 10.1053/j.ajkd.2017.11.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 11/08/2017] [Indexed: 12/19/2022]
Abstract
Current trends in managing atherosclerotic renal artery stenosis favor medical therapy, on account of negative results from prospective trials of revascularization, such as CORAL and ASTRAL. One result of this trend has been encountering occasional patients with progressive disease, sometimes leading to total arterial occlusion. We illustrate a case of accelerated hypertension with complete renal artery occlusion in which the patient recovered function after surgical bypass and we review the clinical approach used and the advanced imaging modalities available to us. A high index of suspicion and careful radiologic imaging play important roles in selecting patients who may have residual function and may benefit from revascularization. This case illustrates an example whereby restoring renal artery perfusion for carefully selected patients can be life changing, with recovery of kidney function and improved blood pressure, pill burden, and overall quality of life.
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Affiliation(s)
- Sandhya Manohar
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester MN
| | | | | | - Stephen C Textor
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester MN.
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24
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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.
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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
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25
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Karanikola E, Karaolanis G, Galyfos G, Barbaressos E, Palla V, Filis K. Endovascular Management of Atherosclerotic Renal Artery Stenosis: Post-Cardiovascular Outcomes in Renal Atherosclerotic Lesions Era Winner or False Alarm? Vasc Specialist Int 2017; 33:1-15. [PMID: 28377906 PMCID: PMC5374954 DOI: 10.5758/vsi.2017.33.1.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 01/10/2017] [Accepted: 01/10/2017] [Indexed: 12/25/2022] Open
Abstract
Renal artery stenosis (RAS) is frequently associated with severe comorbidities such as reduced renal perfusion, hypertension, and end-stage renal failure. In approximately 90% of patients, renal artery atherosclerosis is the main cause for RAS, and it is associated with an increased risk for fatal and non-fatal cardiovascular and renal complications. Endovascular management of atherosclerotic RAS (ARAS) has been recently evaluated by several randomized controlled trials that failed to demonstrate benefit of stenting. Furthermore, the Cardiovascular Outcomes in Renal Atherosclerotic Lesions study did not demonstrate any benefit over the revascularization approach. In this review, we summarized the available data from retrospective, prospective and randomized trials on ARAS to provide clinicians with sufficient data in order to produce useful conclusions for everyday clinical practice.
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Affiliation(s)
- Evridiki Karanikola
- Division of Vascular Surgery, 1st Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration General Hospital, Athens, Greece
| | - Georgios Karaolanis
- Vascular Surgery Unit, 1st Department of Surgery, University of Athens Medical School, Laikon General Hospital, Athens, Greece
| | - George Galyfos
- Division of Vascular Surgery, 1st Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration General Hospital, Athens, Greece
| | - Emmanuel Barbaressos
- Division of Vascular Surgery, 1st Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration General Hospital, Athens, Greece
| | - Viktoria Palla
- Vascular Surgery Unit, 1st Department of Surgery, University of Athens Medical School, Laikon General Hospital, Athens, Greece
| | - Konstantinos Filis
- Division of Vascular Surgery, 1st Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration General Hospital, Athens, Greece
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26
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Vassallo D, Ritchie J, Green D, Chrysochou C, Kalra PA. The effect of revascularization in patients with anatomically significant atherosclerotic renovascular disease presenting with high-risk clinical features. Nephrol Dial Transplant 2017; 33:497-506. [DOI: 10.1093/ndt/gfx025] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 01/28/2017] [Indexed: 12/21/2022] Open
Affiliation(s)
- Diana Vassallo
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - James Ritchie
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - Darren Green
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | | | - Philip A Kalra
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, UK
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28
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Abstract
Atherosclerotic renal artery stenosis is the leading cause of secondary hypertension; it can also cause progressive renal insufficiency and cardiovascular complications such as refractory heart failure and flash pulmonary edema. Medical therapy including risk factor modification, renin-angiotensin-aldosterone system antagonists, lipid lowering agents, and antiplatelet therapy is the first line of treatment in all patients. Patients with uncontrolled renovascular hypertension despite optimal medical therapy, ischemic nephropathy, and cardiac destabilization syndromes who have severe renal artery stenosis are likely to benefit from renal artery revascularization. Screening for renal artery stenosis can be done with Doppler ultrasonography, computed tomographic angiography and magnetic resonance angiography. Invasive physiologic measurements are useful to confirm the severity of renal hypoperfusion and therefore improve the selection patients likely to respond to renal artery revascularization. Primary patency exceeds 80% at 5 years and surveillance for in-stent restenosis can be done with periodic clinical, laboratory, and imaging follow-up.
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Yu MS, Xiang K, Haller ST, Cooper CJ. Renal Artery Interventions. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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A case of atherosclerotic renal artery stenosis involving successful withdrawal from hemodialysis after percutaneous transluminal renal artery stenting. Int J Cardiol 2016; 223:669-671. [PMID: 27568986 DOI: 10.1016/j.ijcard.2016.08.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/03/2016] [Indexed: 11/22/2022]
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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.
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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
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Tuttle KR, Dworkin LD, Henrich W, Greco BA, Steffes M, Tobe S, Shapiro JI, Jamerson K, Lyass A, Pencina K, Massaro JM, D’Agostino RB, Cutlip DE, Murphy TP, Cooper CJ. Effects of Stenting for Atherosclerotic Renal Artery Stenosis on eGFR and Predictors of Clinical Events in the CORAL Trial. Clin J Am Soc Nephrol 2016; 11:1180-1188. [PMID: 27225988 PMCID: PMC4934844 DOI: 10.2215/cjn.10491015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 04/05/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND OBJECTIVES Atherosclerotic renal artery stenosis may cause kidney function loss, but effects of stenting on eGFR and clinical events associated with CKD are uncertain. Our study objectives were to determine effects of stenting on eGFR and predictors of clinical events. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Participants (n=931) in the Cardiovascular Outcomes in Renal Artery Stenosis Trial (from May of 2005 to September of 2012) had >60% atherosclerotic renal artery stenosis and systolic hypertension on two or more antihypertensive drugs and/or stage ≥3 CKD. The intervention was stenting versus no stenting on a background of risk factor management: renin-angiotensin system inhibition, statin, antiplatelet therapy, and smoking cessation education. The effect of stenting on eGFR by the serum creatinine-cystatin C Chronic Kidney Disease Epidemiology Collaboration equation was the prespecified analysis of kidney function. Predictors of eGFR and CKD outcomes (≥30% eGFR loss, ESRD, and death) and cardiovascular disease outcomes (stroke, myocardial infarction, heart failure, and death) controlling for eGFR and albuminuria were also determined. RESULTS eGFR was 59±24 ml/min per 1.73 m(2) (mean±SD) at baseline. Over 3 years, eGFR change, assessed by generalized estimating equations, was -1.5±7.0 ml/min per 1.73 m(2) per year in the stent group versus -2.3±6.3 ml/min per 1.73 m(2) per year in the medical therapy only group (P=0.18). eGFR predictors (multiple variable generalized estimating equations) were age, albuminuria, systolic BP, and diabetes (inverse associations) as well as men, total cholesterol, and HDL cholesterol (positive associations). CKD outcomes events occurred in 19% (175 of 931), and predictors (Cox proportional hazards models) included albuminuria (positive association), systolic BP (positive association), and HDL cholesterol (inverse association). Cardiovascular disease outcomes events occurred in 22% (207 of 931), and predictors included age, albuminuria, total cholesterol, prior cardiovascular disease, and bilateral atherosclerotic renal artery stenosis (positive associations). CONCLUSIONS Stenting did not influence eGFR in participants with atherosclerotic renal artery stenosis receiving renin-angiotensin system inhibition-based therapy. Predictors of clinical events were traditional risk factors for CKD and cardiovascular disease.
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Affiliation(s)
| | - Lance D. Dworkin
- Brown University, Providence, Rhode Island
- Rhode Island Hospital, Providence, Rhode Island
| | - William Henrich
- University of Texas Health Science Center, San Antonio, Texas
| | | | | | | | | | | | - Asya Lyass
- Harvard Clinical Research Institute, Boston University, Boston, Massachusetts
| | - Karol Pencina
- Harvard Clinical Research Institute, Boston University, Boston, Massachusetts
| | - Joseph M. Massaro
- Harvard Clinical Research Institute, Boston University, Boston, Massachusetts
| | - Ralph B. D’Agostino
- Harvard Clinical Research Institute, Boston University, Boston, Massachusetts
| | - Donald E. Cutlip
- Beth Israel Deaconess Medical Center, Boston, Massachusetts; and
| | - Timothy P. Murphy
- Brown University, Providence, Rhode Island
- Rhode Island Hospital, Providence, Rhode Island
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Affiliation(s)
- Jonathan Chester
- Department of Obstetrics and Gynaecology, Alexandra Hospital, Woodrow Drive, Redditch, UK and
| | - Fidan Israfil-Bayli
- Department of Obstetrics and Gynaecology, City Hospital, Dudley Road, Birmingham, UK
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Abstract
The diagnosis of renal artery stenosis (RAS) has become increasingly common in part due to greater awareness of ischemic renal disease and increased use of diagnostic techniques. Over 90 % of RAS cases are caused by atherosclerotic renovascular disease (ARVD). Patients with ARVD are at high risk for fatal and nonfatal cardiovascular and renal events. The mortality rate in patients with ARVD is high, especially with other cardiovascular or renal comorbidities. Recent clinical studies have provided substantial evidence concerning medical therapy and endovascular interventional therapeutic approaches for ARVD. Despite previous randomized clinical trials, the optimal therapy for ARVD remained uncertain until the results of the Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial were released recently. CORAL demonstrated that optimal medical therapy was equally effective to endovascular therapy in the treatment of ARVD. Clinicians can now practice with more evidence-based medicine to treat ARVD and potentially decrease mortality in patients with ARVD using optimal medical therapy.
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Caielli P, Frigo AC, Pengo MF, Rossitto G, Maiolino G, Seccia TM, Calò LA, Miotto D, Rossi GP. Treatment of atherosclerotic renovascular hypertension: review of observational studies and a meta-analysis of randomized clinical trials. Nephrol Dial Transplant 2015; 30:541-553. [DOI: 10.1093/ndt/gfu072] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Emergent unilateral renal artery stenting for treatment of flash pulmonary edema: fact or fiction? Case Rep Cardiol 2015; 2015:659306. [PMID: 25793128 PMCID: PMC4352438 DOI: 10.1155/2015/659306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 01/08/2015] [Accepted: 02/12/2015] [Indexed: 11/17/2022] Open
Abstract
Flash pulmonary edema is characteristically sudden in onset with rapid resolution once appropriate therapy has been instituted (Messerli et al., 2011). Acute increase of left ventricular (LV) end diastolic pressure is the usual cause of sudden decompensated cardiac failure in this patient population. Presence of bilateral renal artery stenosis or unilateral stenosis in combination with a single functional kidney in the susceptible cohort is usually blamed for this condition. We describe a patient who presented with flash pulmonary edema in the setting of normal coronary arteries. Our case is distinct as our patient developed flash pulmonary edema secondary to unilateral renal artery stenosis in the presence of bilateral functioning kidneys. Percutaneous stent implantation in the affected renal artery resulted in rapid resolution of pulmonary edema.
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Abstract
Atherosclerotic renovascular disease is the most common cause of secondary hypertension. The patients with renovascular disease are at increased risk for adverse cardiac outcomes. Recent trials comparing medical therapy alone to medical therapy with stenting are flawed, but lay to rest any existing debate that unselected revascularization is unwarranted; however, revascularization may be appropriate in high-risk populations. Defining an appropriate population for revascularization is an area of ongoing study. Furthermore, delivery of optimal medical therapy in this population is inadequate. This review describes recent developments in renal artery revascularization.
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Affiliation(s)
- Sharon S Choi
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
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Parikh SA, Shishehbor MH, Gray BH, White CJ, Jaff MR. SCAI expert consensus statement for renal artery stenting appropriate use. Catheter Cardiovasc Interv 2014; 84:1163-71. [PMID: 25138644 DOI: 10.1002/ccd.25559] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Accepted: 05/25/2014] [Indexed: 11/08/2022]
Abstract
The pathophysiology of atherosclerotic renal artery stenosis (RAS) includes activation of the renin-angiotensin-aldosterone axis with resultant renovascular hypertension. Renal artery stenting has emerged as the primary revascularization strategy in most patients with hemodynamically significant atherosclerotic RAS. Despite the frequency with which hemodynamically significant RAS is observed and high rates of technical success of renal artery stenting, there remains considerable debate among experts regarding the role of medical therapy versus revascularization for renovascular hypertension. Modern, prospective, multicenter registries continue to demonstrate improvement in systolic and diastolic blood pressure with excellent safety profiles in patients with RAS. Modern randomized, controlled clinical trials of optimal medical therapy versus renal stenting particularly designed to demonstrate preservation in renal function after renal artery stenting have demonstrated limited benefit. However, these trials frequently excluded patients that may benefit from renal artery stenting. This document was developed to guide physicians in the modern practical application of renal stenting, to highlight the current limitations in the peer-reviewed literature, to suggest best-practices in the performance of renal stenting and to identify opportunities to advance the field.
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Affiliation(s)
- Sahil A Parikh
- University Hospitals Case Medical Center, Harrington Heart and Vascular Institute and Case Western Reserve University School of Medicine, Cleveland, Ohio
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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.
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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.
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Tafur-Soto J, White CJ. Selecting patients likely to benefit from renal artery stenting. Interv Cardiol 2014. [DOI: 10.2217/ica.14.6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
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Peixoto AJ, Ditchel LM, Santos SFF. Management of atherosclerotic renal artery stenosis. Expert Rev Cardiovasc Ther 2014; 8:1317-24. [DOI: 10.1586/erc.10.85] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Textor SC. Attending rounds: a patient with accelerated hypertension and an atrophic kidney. Clin J Am Soc Nephrol 2014; 9:1117-23. [PMID: 24408123 DOI: 10.2215/cjn.09030813] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This case represents an individual with accelerating hypertension and declining kidney function associated with atherosclerotic renal artery stenosis. Key features include loss of GFR (reaching stage V CKD) during intensified antihypertensive drug therapy including agents that block the renin-angiotensin system and failure to appreciate the extent to which moderate renal artery stenosis was affecting his better kidney. Interpretation of duplex ultrasound studies was complicated by a discrepancy between near-normal peak systolic velocities and markedly abnormal segmental arterial waveforms. It was essential to recognize that both kidneys were abnormal and focus on recovery of perfusion to the better of these kidneys. Successful revascularization of one kidney allowed major improvement in GFR and BP control.
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Sawai T, Miyahara M, Okamoto R, Dohi K, Tanigawa T, Yamada N, Nakamura M, Ito M. Marked improvement of renal failure and severe hypertension after renal artery stenting in the solitary functioning kidney. J Cardiol Cases 2013; 7:e82-e85. [PMID: 30533129 DOI: 10.1016/j.jccase.2012.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 11/04/2012] [Accepted: 12/04/2012] [Indexed: 12/01/2022] Open
Abstract
Atherosclerotic renal artery stenosis (ARAS) can cause resistant hypertension, progressive renal failure and/or cardiorenal syndrome. Although no randomized study to demonstrate the superiority of renal stenting over medical treatment is available, a case-sensitive approach is required for the treatment of ARAS. Here, we describe a case report of a symptomatic ARAS patient with a solitary functioning kidney in which successful detection of ARAS by ultrasonography examination with the Doppler method and timely renal artery stenting were performed. <Learning objective: The clinical efficacy of renal artery stenting for symptomatic ARAS as a method of lowering blood pressure and preventing deterioration in renal function remains unproven. However, renal artery stenting performed based on enough investigation of clinical course and information by ultrasonography examination with Doppler method results in benefit to the patient with ARAS.>.
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Affiliation(s)
- Toshiki Sawai
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Masatoshi Miyahara
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Ryuji Okamoto
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Kaoru Dohi
- Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, Tsu, Japan
| | - Takashi Tanigawa
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Norikazu Yamada
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Mashio Nakamura
- Department of Clinical Cardiovascular Research, Mie University Graduate School of Medicine, Tsu, Japan
| | - Masaaki Ito
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
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Yamashita T, Tsutsui H. [Atherosclerosis: progress in diagnosis and treatments. Topics: IV. Progress in treatments of atherosclerosis; 4. Renal artery stenosis]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2013; 102:381-391. [PMID: 23767319 DOI: 10.2169/naika.102.381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Takehiro Yamashita
- Department of Cardiology, Cardiovascular Center Hokkaido Ohno Hospital, Japan
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Textor SC, Misra S, Oderich GS. Percutaneous revascularization for ischemic nephropathy: the past, present, and future. Kidney Int 2012; 83:28-40. [PMID: 23151953 PMCID: PMC3532568 DOI: 10.1038/ki.2012.363] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Occlusion of the renal arteries can threaten the viability of the kidney when severe, in addition to accelerating hypertension and circulatory congestion. Renal artery stenting procedures have evolved from a treatment mainly for renovascular hypertension to a maneuver capable of recovering threatened renal function in patients with “ischemic nephropathy” and improving management of congestive heart failure. Improved catheter design and techniques have reduced, but not eliminated hazards associated with renovascular stenting. Expanded use of endovascular stent grafts to treat abdominal aortic aneurysms has introduced a new indication for renal artery stenting to protect the renal circulation when grafts cross the origins of the renal arteries. Although controversial, prospective randomized trials to evaluate the added benefit of revascularization to current medical therapy for atherosclerotic renal artery stenosis until now have failed to identify major benefits regarding either renal function or blood pressure control. These studies have been limited by selection bias and have been harshly criticized. While studies of tissue oxygenation using blood oxygen level dependent (BOLD) MR establish that kidneys can adapt to reduced blood flow to some degree, more severe occlusive disease leads to cortical hypoxia associated with microvascular rarefication, inflammatory injury and fibrosis. Current research is directed toward identifying pathways of irreversible kidney injury due to vascular occlusion and to increase the potential for renal repair after restoring renal artery patency. The role of nephrologists likely will focus upon recognizing the limits of renal adaptation to vascular disease and identifying kidneys truly at risk for ischemic injury at a time point when renal revascularization can still be of benefit to recovering kidney function.
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Affiliation(s)
- Stephen C Textor
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA.
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Eirin A, Ebrahimi B, Zhang X, Zhu XY, Tang H, Crane JA, Lerman A, Textor SC, Lerman LO. Changes in glomerular filtration rate after renal revascularization correlate with microvascular hemodynamics and inflammation in Swine renal artery stenosis. Circ Cardiovasc Interv 2012; 5:720-8. [PMID: 23048054 DOI: 10.1161/circinterventions.112.972596] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The selection of patients with renal artery stenosis (RAS) likely to improve glomerular filtration rate (GFR) after percutaneous transluminal renal angioplasty is difficult. We examined basal hemodynamic and inflammatory factors linked to improved stenotic kidney (STK) function after percutaneous transluminal renal angioplasty in swine RAS. METHODS AND RESULTS Fifteen pigs after 6 weeks of hemodynamically significant RAS were studied before and 4 weeks after technically successful percutaneous transluminal renal angioplasty+stenting. STK and contralateral kidney hemodynamics and function were evaluated by multidetector computed-tomography before and after acetylcholine challenge. Single-kidney deoxyhemoglobin (R2*, reciprocal to blood relaxation) and energy-dependent tubular function were assessed using blood-oxygen-level-dependent magnetic resonance imaging before and after furosemide. Baseline renal vein and inferior vena cava levels of inflammatory markers were measured and their gradient and net release calculated. Baseline parameters were compared with normal (n=7) and sham-RAS (n=7) pigs and correlated with the change in STK-GFR after revascularization (ΔGFR). Four weeks after percutaneous transluminal, renal angioplasty blood pressure was normalized in all animals, but STK-GFR improved in 10 of 15 (ΔGFR =+22.0±8.5 mL/min). ΔGFR correlated inversely with basal STK-GFR, renal release of inflammatory markers, and medullary R2* response to furosemide, but directly with GFR response to acetylcholine. Basal contralateral kidney GFR correlated directly with ΔGFR. CONCLUSIONS Low basal STK-GFR with preserved response to acetylcholine may predict benefit from revascularization in RAS, whereas renal inflammation and robust STK-R2* responses to furosemide (possibly reflecting avid tubular oxygen consumption) are associated with less favorable outcomes. These tools may be useful for identification of patients likely to improve renal function after revascularization.
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Affiliation(s)
- Alfonso Eirin
- Divisions of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Jaff MR, Bates M, Sullivan T, Popma J, Gao X, Zaugg M, Verta P. Significant reduction in systolic blood pressure following renal artery stenting in patients with uncontrolled hypertension: results from the HERCULES trial. Catheter Cardiovasc Interv 2012; 80:343-50. [PMID: 22511402 DOI: 10.1002/ccd.24449] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 04/12/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND Atherosclerotic renal artery stenosis (ARAS) causes hypertension (HTN) and threatens renal function (RF). The HERCULES Trial is a prospective, multicenter trial of renal stenting in patients with uncontrolled HTN and ARAS evaluating the safety and effectiveness of the RX Herculink Elite Renal Stent System (Abbott Vascular, Santa Clara, CA). METHODS A total of 202 patients (241 total lesions; 78 bilateral lesions) were enrolled between August 2007 and October 2009. The primary endpoint was 9-month binary restenosis determined by duplex ultrasound and/or angiography. Secondary endpoints included changes in blood pressure, antihypertensive medications, and RF between baseline and 9 months. Brain natriuretic peptide (BNP) was measured at baseline, 24 hr and 30 days postprocedure. RESULTS Mean systolic blood pressure (SBP) at baseline was 162 mm Hg. Nearly 70% of patients were receiving three or more antihypertensive medications (mean 3.4 medications per patient). Baseline serum creatinine was 1.2 ± 0.4 and 61.5% of subjects had estimated glomerular filtration <60. The restenosis rate was 10.5% at 9 months. The study device, procedure, and clinical success rates were 96.0, 99.2, and 98.0%, respectively. Freedom from major adverse events was 94.8%. At 9 months, the mean SBP significantly decreased (mean 145, paired t test P < 0.0001) after stenting with no change in medications. There was no correlation between SBP reduction and baseline BNP or BNP reduction. CONCLUSIONS HERCULES demonstrates clinically and statistically significant SBP reduction in patients with uncontrolled HTN, low in-stent restenosis, and complication rates. This study highlights that when appropriate patients are selected for renal artery stenting, impressive reductions in blood pressure may be anticipated. Although the magnitude of absolute reduction in SBP was related to baseline SBP, elevated baseline BNP levels were not predictive of reduction in SBP. Further studies for predictors of clinical response following percutaneous renal revascularization are needed.
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Affiliation(s)
- Michael R Jaff
- The Vascular Center, Massachusetts General Hospital, Boston, Massachusetts, USA.
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