From the 1990s to CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) trial results and beyond: does stenting have a role in ischemic nephropathy?

Prevalence and Associated Factors of Atherosclerotic Plaque and Stenosis in Renal Arteries: A Community-Based Study

The epidemiology of renal artery atherosclerosis in community populations is poorly documented. This study aimed to determine the prevalence of renal artery plaque (RAP) and atherosclerotic renal artery stenosis (ARAS), and the association of plaque and stenosis with vascular risk factors and kidney disease markers among community-dwelling adults. We conducted a cross-sectional analysis of the Polyvascular Evaluation for Cognitive Impairment and Vascular Events (PRECISE) study. RAP and ARAS were evaluated by thoracoabdominal computed tomography angiography. A total of 3045 adults aged 50-75 years were included. The prevalence of RAP and ARAS was 28.7% and 4.8%, respectively. The prevalence of RAP and ARAS was 41.3% and 7.7% in individuals aged ≥60 years, 42.9% and 8.7% in hypertensives, and 45.4% and 8.5% in individuals with chronic kidney disease. Older age, hypertension, higher total cholesterol level, and lower high-density lipoprotein cholesterol level were independently associated with RAP and ARAS. A higher urinary albumin-creatinine ratio was independently associated with RAP, whereas a reduced estimated glomerular filtration rate was independently associated with ARAS. In conclusion, there was a non-negligible prevalence of RAP and ARAS among the older, community population in China.

Endovascular treatment of renal artery stenosis in Germany: a retrospective analysis of the DEGIR registry 2018-2021

PURPOSE

To provide an overview of endovascular treatment of renal artery stenosis (RAS) using the data of the Deutsche Gesellschaft für interventionelle Radiologie (DeGIR) quality management system.

MATERIALS AND METHODS

A retrospective analysis was performed. Pre-, peri- and postprocedural data, technical success rates, complication rates, and clinical success rates at dismissal were examined.

RESULTS

Between 2018 and 2021, 2134 angiography examinations of the renal arteries were performed: diagnostic angiography in 70 patients (3 %), balloon angioplasty in 795 (37 %), stent implantation in 1166 (55 %) and miscellaneous procedures in 103 (5 %). The lesion length was less than or equal to 5 mm in 1837 patients (87 %), between 5 and 10 mm in 197 (9 %), and between 10 and 20 mm in 62 (3 %). The degree of stenosis was less than 50 % in 156 patients (7 %), greater than 50 % in 239 (11 %), and greater than 70 % in 1472 (70 %). Occlusion was treated in 235 patients (11 %). Symptoms at discharge resolved in 600 patients (29 %), improved in 1012 (49 %), were unchanged in 77 (4 %), and worsened in 5 (0.2 %). Complications were reported in 51 patients (2.5 %) and the mortality rate was 0.15 %.

CONCLUSION

A substantial number of patients with RAS and occlusions were treated by radiologists in Germany, with high technical success rates and low complication rates. The indication should be determined carefully as the current European guidelines for the treatment of RAS suggest that only carefully selected groups of patients will benefit from recanalizing treatment.

KEY POINTS

· Carefully selected patient groups may benefit from endovascular treatment of renal artery stenosis.. · Analysis of the DEGIR quality management database shows that treatment of renal artery stenosis was performed by radiologists in Germany with high technical success rates and low complication rates.. · Recanalization even led to symptom improvement in a large proportion of patients with occlusions..

Prevalence and Vascular Distribution of Multiterritorial Atherosclerosis Among Community-Dwelling Adults in Southeast China

IMPORTANCE

Data are limited on the prevalence and vascular distribution of multiterritorial atherosclerotic plaque and stenosis in community populations.

OBJECTIVE

To investigate the prevalence and vascular distribution of multiterritorial atherosclerotic plaque and stenosis in older, community-dwelling populations in China.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was based on the baseline survey from the Polyvascular Evaluation for Cognitive Impairment and Vascular Events (PRECISE) study, a population-based prospective cohort study that enrolled community-dwelling adults aged 50 to 75 years based on cluster sampling from 6 villages and 4 living communities of Lishui city in southeast China. Data were collected from May 2017 to September 2019 and analyzed from September to November 2021.

MAIN OUTCOMES AND MEASURES

Atherosclerotic plaque and stenosis at baseline were assessed in multiple vascular territories. Brain vessel wall magnetic resonance imaging (MRI) for intracranial and extracranial arteries; computed tomography angiography (CTA) for coronary, subclavian, aorta, renal, and iliofemoral arteries; and ankle-brachial index for peripheral arteries were performed at baseline survey. The extent of atherosclerosis was assessed according to the number of these 8 vascular sites affected, and polyvascular lesions were defined as at least 2 affected sites.

RESULTS

A total of 3433 of 4202 invited individuals consented to participate in the study. After excluding 366 participants with contraindications for MRI or CTA scanning, with life expectancies of 4 years of fewer, or with mental disease, a total of 3067 community-dwelling adults were enrolled. The mean (SD) age was 61.2 (6.7) years; 1640 (53.5%) were women, and 74 (2.4%) had prevalent ASCVD. Most participants (2870 [93.6%]) had atherosclerotic plaques in at least 1 vascular territory. Atherosclerotic plaques were mostly detected in the aorta (2419 [79.6%]) and iliofemoral arteries (2312 [75.8%]), followed by subclavian (1500 [49.8%]), coronary (1366 [44.9%]), extracranial (1110 [36.4%]), renal (873 [28.7%]), and intracranial (542 [17.7%]) arteries. A substantial proportion of participants (1180 [38.5%]) had arterial stenosis of 50% or greater, predominantly affecting the coronary (542 [17.8%]) and iliofemoral (527 [17.3%]) arteries. Polyvascular atherosclerotic plaque was observed in 2541 participants (82.8%), with 1436 (46.8%) with plaque affecting 4 or more vascular territories, and polyvascular stenosis was observed in 412 patients (13.4%).

CONCLUSIONS AND RELEVANCE

In this study, atherosclerotic plaque was highly prevalent in the older community population in China, and a substantial proportion of individuals reach stenosis of 50% or greater.

Renal Artery Revascularization a controversial treatment strategy for Renal Artery Stenosis. A case series and a brief review of current literature

Renal artery stenosis (RAS) may cause secondary hypertension, progressive decline in renal function, and cardiac destabilization syndromes including "flash" pulmonary edema, recurrent congestive heart failure, and cerebro-cardiovascular disease. Atherosclerotic lesions, fibromuscular dysplasia and vasculitides are the pathophysiologic basis of the disease. Common therapeutic pathways for RAS include medical therapy and revascularization with or without stenting. Randomized controlled trials evaluating renal revascularization, did not report any advantage of revascularization over medical therapy alone in terms of renal function improvement or prevention of cardiovascular events. However, mounting clinical experience suggests that the best strategy in RAS management is identifying which patients are most likely to benefit from renal artery stenting and also optimizing the safety and durability of the procedure. This review presents 3 cases of patients who undergone renal revascularization and discusses the available clinical evidence for identification of RAS patients who will potentially respond well to revascularization.

Renal Fibrosis Is Significantly Attenuated Following Targeted Disruption of Cd40 in Experimental Renal Ischemia

Background

Renal artery stenosis is a common cause of renal ischemia, contributing to the development of chronic kidney disease. To investigate the role of local CD40 expression in renal artery stenosis, Goldblatt 2‐kidney 1‐clip surgery was performed on hypertensive Dahl salt‐sensitive rats (S rats) and genetically modified S rats in which CD40 function is abolished (Cd40^mutant).

Methods and Results

Four weeks following the 2‐kidney 1‐clip procedure, Cd40^mutant rats demonstrated significantly reduced blood pressure and renal fibrosis in the ischemic kidneys compared with S rat controls. Similarly, disruption of Cd40 resulted in reduced 24‐hour urinary protein excretion in Cd40^mutant rats versus S rat controls (46.2±1.9 versus 118.4±5.3 mg/24 h; P<0.01), as well as protection from oxidative stress, as indicated by increased paraoxonase activity in Cd40^mutant rats versus S rat controls (P<0.01). Ischemic kidneys from Cd40^mutant rats demonstrated a significant decrease in gene expression of the profibrotic mediator, plasminogen activator inhibitor‐1 (P<0.05), and the proinflammatory mediators, C‐C motif chemokine ligand 19 (P<0.01), C‐X‐C Motif Chemokine Ligand 9 (P<0.01), and interleukin‐6 receptor (P<0.001), compared with S rat ischemic kidneys, as assessed by quantitative PCR assay. Reciprocal renal transplantation documented that CD40 exclusively expressed in the kidney contributes to ischemia‐induced renal fibrosis. Furthermore, human CD40‐knockout proximal tubule epithelial cells suggested that suppression of CD40 signaling significantly inhibited expression of proinflammatory and ‐fibrotic genes.

Conclusions

Taken together, our data suggest that activation of CD40 induces a significant proinflammatory and ‐fibrotic response and represents an attractive therapeutic target for treatment of ischemic renal disease.

Kidney-resident macrophages promote a proangiogenic environment in the normal and chronically ischemic mouse kidney

Renal artery stenosis (RAS) caused by narrowing of arteries is characterized by microvascular damage. Macrophages are implicated in repair and injury, but the specific populations responsible for these divergent roles have not been identified. Here, we characterized murine kidney F4/80+CD64+ macrophages in three transcriptionally unique populations. Using fate-mapping and parabiosis studies, we demonstrate that CD11b/cint are long-lived kidney-resident (KRM) while CD11chiMϕ, CD11cloMϕ are monocyte-derived macrophages. In a murine model of RAS, KRM self-renewed, while CD11chiMϕ and CD11cloMϕ increased significantly, which was associated with loss of peritubular capillaries. Replacing the native KRM with monocyte-derived KRM using liposomal clodronate and bone marrow transplantation followed by RAS, amplified loss of peritubular capillaries. To further elucidate the nature of interactions between KRM and peritubular endothelial cells, we performed RNA-sequencing on flow-sorted macrophages from Sham and RAS kidneys. KRM showed a prominent activation pattern in RAS with significant enrichment in reparative pathways, like angiogenesis and wound healing. In culture, KRM increased proliferation of renal peritubular endothelial cells implying direct pro-angiogenic properties. Human homologs of KRM identified as CD11bintCD11cintCD68+ increased in post-stenotic kidney biopsies from RAS patients compared to healthy human kidneys, and inversely correlated to kidney function. Thus, KRM may play protective roles in stenotic kidney injury through expansion and upregulation of pro-angiogenic pathways.

Successful Treatment of Resistant Hypertension by Means of Chronic Renal Artery Occlusion Revascularization in a Fragile Patient

BACKGROUND

Renal artery stenosis is a common cause of secondary hypertension refractory to medical therapy. Percutaneous angioplasty along with metallic stent placement has been described as an effective treatment for revascularization of the renal artery.

CASE REPORT

A 54-year-old woman affected by paranoid schizophrenia with a history of hypertension and chronic renal failure due to renal artery occlusion was treated by endovascular recanalization and stent placement that resulted in improvement of renal function and control of hypertension. Laboratory studies 4 months after the revascularization revealed blood creatinine decrease gradually from 8.57 mg/dL to 3 mg/dL.

CONCLUSIONS

Revascularization with stenting has proven to be a safe and effective procedure in the treatment of total renal artery occlusion which also led to a significant relief at a psychological level.

Risk factors associated with end-stage renal disease (ESRD) in patients with atherosclerotic renal artery stenosis: a nationwide population-based analysis

The aim of this study was to investigate the risk factors associated with end-stage renal disease (ESRD) in patients with atherosclerotic renal artery stenosis (ARAS). Information about the study participants was extracted from the National Health Insurance Research Database of Taiwan for the years 1999 through 2011. We conducted this retrospective cohort study of patients with ARAS to identify the potential risk factors associated with long-term renal outcomes. A total of 2184 patients with ARAS were enrolled, of whom 840 had ESRD and were classified as the study group, and 1344 patients who were without ESRD were included in the comparison cohort. After adjusting for related variables, univariable, and multivariable logistic regression analysis showed that ESRD was associated with higher Charlson-comorbidity index (CCI) score (adjusted odds ratio [OR] = 6.78, 95% CI = 4.59-10.0 for CCI = 2; adjusted OR = 20.0, 95% CI = 13.7-29.2 for CCI ≥3), diabetes (adjusted OR = 1.55, 95% CI = 1.24-1.93), hypertension (adjusted OR = 3.66, 95% CI = 2.36-5.66), and age 20 to 49-years old (adjusted OR = 2.14, 95% CI = 1.51-3.03). Moreover, our data showed that renal artery revascularization (RAR) was significantly associated with a lower risk of ESRD in ARAS patients (crude OR = 0.64, 95% CI = 0.50-0.84). Our study is the first to disclose that CCI score was significantly associated with the risk of ESRD in ARAS patients, and comorbid diseases including diabetes mellitus and hypertension significantly affect renal outcomes in patients with ARAS. Of note, our data showed that renal artery revascularization was associated with a lower risk of ESRD in ARAS patients in long-term follow-up.