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Piechocki M, Przewłocki T, Pieniążek P, Trystuła M, Podolec J, Kabłak-Ziembicka A. A Non-Coronary, Peripheral Arterial Atherosclerotic Disease (Carotid, Renal, Lower Limb) in Elderly Patients-A Review: Part I-Epidemiology, Risk Factors, and Atherosclerosis-Related Diversities in Elderly Patients. J Clin Med 2024; 13:1471. [PMID: 38592280 PMCID: PMC10935176 DOI: 10.3390/jcm13051471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/23/2024] [Accepted: 02/29/2024] [Indexed: 04/10/2024] Open
Abstract
Atherosclerosis is a generalized and progressive disease. Ageing is a key risk factor for atherosclerosis progression that is associated with the increased incidence of ischemic events in supplied organs, including stroke, coronary events, limb ischemia, or renal failure. Cardiovascular disease is the leading cause of death and major disability in adults ≥ 75 years of age. Atherosclerotic occlusive disease affects everyday activity and quality of life, and it is associated with reduced life expectancy. Although there is evidence on coronary artery disease management in the elderly, there is insufficient data on the management in older patients presented with atherosclerotic lesions outside the coronary territory. Despite this, trials and observational studies systematically exclude older patients, particularly those with severe comorbidities, physical or cognitive dysfunctions, frailty, or residence in a nursing home. This results in serious critical gaps in knowledge and a lack of guidance on the appropriate medical treatment and referral for endovascular or surgical interventions. Therefore, we attempted to gather data on the prevalence, risk factors, and management strategies in patients with extra-coronary atherosclerotic lesions.
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Affiliation(s)
- Marcin Piechocki
- Department of Vascular and Endovascular Surgery, The St. John Paul II Hospital, Prądnicka 80, 31-202 Krakow, Poland; (M.P.); (P.P.); (M.T.)
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Krakow, Poland;
| | - Tadeusz Przewłocki
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Krakow, Poland;
- Department of Interventional Cardiology, The St. John Paul II Hospital, Prądnicka 80, 31-202 Krakow, Poland;
| | - Piotr Pieniążek
- Department of Vascular and Endovascular Surgery, The St. John Paul II Hospital, Prądnicka 80, 31-202 Krakow, Poland; (M.P.); (P.P.); (M.T.)
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Krakow, Poland;
| | - Mariusz Trystuła
- Department of Vascular and Endovascular Surgery, The St. John Paul II Hospital, Prądnicka 80, 31-202 Krakow, Poland; (M.P.); (P.P.); (M.T.)
| | - Jakub Podolec
- Department of Interventional Cardiology, The St. John Paul II Hospital, Prądnicka 80, 31-202 Krakow, Poland;
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Krakow, Poland
| | - Anna Kabłak-Ziembicka
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Krakow, Poland
- Noninvasive Cardiovascular Laboratory, The St. John Paul II Hospital, Prądnicka 80, 31-202 Krakow, Poland
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Lobo MD, Rull G, Saxena M, Kapil V. Selecting patients for interventional procedures to treat hypertension. Blood Press 2023; 32:2248276. [PMID: 37665430 DOI: 10.1080/08037051.2023.2248276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 09/05/2023]
Abstract
Purpose: Interventional approaches to treat hypertension are an emerging option that may be suitable for patients whose BP control cannot be achieved with lifestyle and/or pharmacotherapy and possibly for those who do not wish to take drug therapy.Materials and Methods: Interventional strategies include renal denervation with radiofrequency, ultrasound and alcohol-mediated platforms as well as baroreflex activation therapy and cardiac neuromodulation therapy. Presently renal denervation is the most advanced of the therapeutic options and is currently being commercialised in the EU.Results: It is apparent that RDN is effective in both unmedicated patients and patients with more severe hypertension including those with resistant hypertension.Conclusion: However, at present there is no evidence for the use of RDN in patients with secondary forms of hypertension and thus evaluation to rule these out is necessary before proceeding with a procedure. Furthermore, there are numerous pitfalls in the diagnosis and management of secondary hypertension which need to be taken into consideration. Finally, prior to performing an intervention it is appropriate to document presence/absence of hypertension-mediated organ damage.
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Affiliation(s)
- Melvin D Lobo
- William Harvey Research Institute, Barts NIHR Biomedical Research Centre, Queen Mary University of London, London, UK
| | - Gurvinder Rull
- William Harvey Research Institute, Barts NIHR Biomedical Research Centre, Queen Mary University of London, London, UK
| | - Manish Saxena
- William Harvey Research Institute, Barts NIHR Biomedical Research Centre, Queen Mary University of London, London, UK
| | - Vikas Kapil
- William Harvey Research Institute, Barts NIHR Biomedical Research Centre, Queen Mary University of London, London, UK
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Kang YY, Chen Y, Wu QH, Dong H, Zou YB, Gao PJ, Xu JZ, Jiang XJ, Wang JG. Prevalence and clinical characteristics of renovascular hypertension associated with fibromuscular dysplasia in China. J Hypertens 2023; 41:638-647. [PMID: 36723459 PMCID: PMC9994795 DOI: 10.1097/hjh.0000000000003382] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 12/12/2022] [Accepted: 01/08/2023] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The aim of this study was to investigate the clinical characteristics of renal artery fibromuscular dysplasia (FMD) in patients in China and identify the cure rate of hypertension after angioplasty. METHODS Consecutive hypertensive patients with renal artery stenosis caused by FMD who underwent catheter-based angiography, and were followed at two Chinese referral centres, were retrospectively analysed. All patients underwent a detailed investigation, including demographic characteristics, clinical characteristics, biochemical sampling, Doppler ultrasonography of carotid arteries, magnetic resonance angiography (MRA) of the intracranial artery, and CTA or MRA of the abdominal artery and catheter-based renal angiography. Patients were routinely followed up at 1 month, 6 months and every year after the procedure. RESULTS Among 245 study participants, with a mean diagnosed age of 26.9 ± 9.9 years, 137 (55.9%) were women, and 38 (15.5%) were children. All patients were diagnosed with hypertension at a mean age of 23.4 ± 8.4 years. There were 73.5% focal and 15.2% multivessel cases. Aneurysms, arterial dissections and total occlusions were found in 21.6, 4.1 and 12.2% of patients, respectively. Patients with multifocal FMD were older (26.0 vs. 23.7 years, P = 0.021) and more often female (70.8 vs. 50.6%, P = 0.004). Among children with renal FMD, 55.2% were men, and 86.8% were focal. After a median follow-up of 7.0 years, multifocal FMD had a higher cure rate of hypertension than focal FMD after revascularization (71.7 vs. 55.8%, P = 0.032). CONCLUSION In a cohort of mostly young Chinese patients, the prevalence of hypertension associated with renal FMD is similar in both sexes. Focal FMDs were more frequent than the multifocal ones and, after angioplasty, were associated with a worse blood pressure outcome.
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Affiliation(s)
- Yuan-Yuan Kang
- Department of Cardiovascular Medicine, Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Yang Chen
- Department of Cardiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qi-Hong Wu
- Department of Cardiovascular Medicine, Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Hui Dong
- Department of Cardiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu-Bao Zou
- Department of Cardiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ping-Jin Gao
- Department of Cardiovascular Medicine, Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Jian-Zhong Xu
- Department of Cardiovascular Medicine, Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Xiong-Jing Jiang
- Department of Cardiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ji-Guang Wang
- Department of Cardiovascular Medicine, Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
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Bassareo PP, Calcaterra G, Sabatino J, Oreto L, Ciliberti P, Perrone M, Martino F, D'Alto M, Chessa M, DI Salvo G, Guccione P. Primary and secondary paediatric hypertension. J Cardiovasc Med (Hagerstown) 2023; 24:e77-e85. [PMID: 37052224 DOI: 10.2459/jcm.0000000000001432] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
High blood pressure (BP) or hypertension is a well known risk factor for developing heart attack, stroke, atrial fibrillation and renal failure. Although in the past hypertension was supposed to develop at middle age, it is now widely recognized that it begins early during childhood. As such, approximately 5-10% of children and adolescents are hypertensive. Unlike that previously reported, it is now widely accepted that primary hypertension is the most diffuse form of high BP encountered even in paediatric age, while secondary hypertension accounts just for a minority of the cases. There are significant differences between that outlined by the European Society of Hypertension (ESH), the European Society of Cardiology (ESC), and the last statement by the American Academy of Pediatrics (AAP) concerning the BP cut-offs to identify young hypertensive individuals. Not only that, but the AAP have also excluded obese children in the new normative data. This is undoubtedly a matter of concern. Conversely, both the AAP and ESH/ESC agree that medical therapy should be reserved just for nonresponders to measures like weight loss/salt intake reduction/increase in aerobic exercise. Secondary hypertension often occurs in aortic coarctation or chronic renal disease patients. The former can develop hypertension despite early effective repair. This is associated with significant morbidity and is arguably the most important adverse outcome in about 30% of these subjects. Also, syndromic patients, for example those with Williams syndrome, may suffer from a generalized aortopathy, which triggers increased arterial stiffness and hypertension. This review summarizes the state-of-the-art situation regarding primary and secondary paediatric hypertension.
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Affiliation(s)
- Pier Paolo Bassareo
- University College of Dublin, School of Medicine, Mater Misericordiae University Hospital and Children's Health Ireland at Crumlin, Dublin, Ireland
| | | | - Jolanda Sabatino
- Division of Paediatric Cardiology, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Lilia Oreto
- Mediterranean Pediatric Cardiology Center, Bambino Gesù Pediatric Hospital, Taormina, Messina
| | - Paolo Ciliberti
- Department of Cardiology, Cardiac Surgery, Heart and Lung Transplantation, IRCCS Bambino Gesu'Paediatric Hospital
| | - Marco Perrone
- Department of Cardiology, Cardiac Surgery, Heart and Lung Transplantation, IRCCS Bambino Gesu'Paediatric Hospital
| | - Francesco Martino
- Department of Internal Clinical, Anesthesiological and Cardiovascular Sciences, La Sapienza University, Rome
| | - Michele D'Alto
- Department of Cardiology, Monaldi Hospital - University 'L. Vanvitelli', Naples
| | - Massimo Chessa
- ACHD UNIT, Pediatric and Adult Congenital Heart Centre, IRCCS-Policlinico San Donato, San Donato Milanese, Vita Salute San Raffaele University, Milan, Italy
| | - Giovanni DI Salvo
- Division of Paediatric Cardiology, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Paolo Guccione
- Department of Cardiology, Cardiac Surgery, Heart and Lung Transplantation, IRCCS Bambino Gesu'Paediatric Hospital
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Hu G, Li G, Huang D, Zou Y, Yuan X, Ritter JK, Li N, Li PL. Renomedullary exosomes produce antihypertensive effects in reversible two-kidney one-clip renovascular hypertensive mice. Biochem Pharmacol 2022; 204:115238. [PMID: 36055382 PMCID: PMC10777442 DOI: 10.1016/j.bcp.2022.115238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 11/02/2022]
Abstract
The rapid fall in blood pressure following unclipping of the stenotic renal artery in the Goldblatt two-kidney one-clip (2K1C) model of renovascular hypertension is proposed to be due to release of renomedullary vasodepressor lipids, but the mechanism has remained unclear. In this study, we hypothesized that the hypotensive response to unclipping is mediated by exosomes released from the renal medulla. In male C57BL6/J mice made hypertensive by the 2K1C surgery, unclipping of the renal artery after 10 days decreased mean arterial pressure (MAP) by 23 mmHg one hr after unclipping. This effect was accompanied by a 556% increase in the concentration of exosomes in plasma as observed by nanoparticle tracking analysis. Immunohistochemical analysis of exosome markers, CD63 and AnnexinII, showed increased staining in interstitial cells of the inner medulla of stenotic but not contralateral control kidney of clipped 2K1C mice. Treatment with rapamycin, an inducer of exosome release, blunted the hypertensive response to clipping, whereas GW-4869, an exosome biosynthesis inhibitor, prevented both the clipping-induced increase in inner medullary exosome marker staining and the unclipping-induced fall in MAP. Plasma exosomes isolated from unclipped 2K1C mice showed elevated neutral lipid content compared to sham mouse exosomes by flow cytometric analysis after Nile red staining. Exosomes from 2K1C but not sham control mice exerted potent MAP-lowering and diuretic-natriuretic effects in both 2K1C and angiotensin II-infused hypertensive mice. These results are consistent with increased renomedullary synthesis and release of exosomes with elevated antihypertensive neutral lipids in response to increased renal perfusion pressure.
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Affiliation(s)
- Gaizun Hu
- Department of Pharmacology and Toxicology, School of Medicine, Virginia Commonwealth University, Richmond VA23298, United States
| | - Guangbi Li
- Department of Pharmacology and Toxicology, School of Medicine, Virginia Commonwealth University, Richmond VA23298, United States
| | - Dandan Huang
- Department of Pharmacology and Toxicology, School of Medicine, Virginia Commonwealth University, Richmond VA23298, United States
| | - Yao Zou
- Department of Pharmacology and Toxicology, School of Medicine, Virginia Commonwealth University, Richmond VA23298, United States
| | - Xinxu Yuan
- Department of Pharmacology and Toxicology, School of Medicine, Virginia Commonwealth University, Richmond VA23298, United States
| | - Joseph K Ritter
- Department of Pharmacology and Toxicology, School of Medicine, Virginia Commonwealth University, Richmond VA23298, United States
| | - Ningjun Li
- Department of Pharmacology and Toxicology, School of Medicine, Virginia Commonwealth University, Richmond VA23298, United States
| | - Pin-Lan Li
- Department of Pharmacology and Toxicology, School of Medicine, Virginia Commonwealth University, Richmond VA23298, United States.
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Milošević M, Otašević P. Treatment-resistant hypertension. ARHIV ZA FARMACIJU 2022. [DOI: 10.5937/arhfarm72-34248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Treatment-resistant hypertension is one of the most significant causes of poor blood pressure regulation. Patients with resistant hypertension are at a higher risk of developing comorbidities compared to the general hypertensive population. As a result, these patients have an increased incidence of disability and premature death, as well as increased treatment costs. Due to the above-mentioned, in the last decade, there has been an increase in researchers' interest in elucidating the pathogenesis, diagnosis, and treatment of resistant hypertension. However, recent data indicate that 20% of female and 24% of male patients with arterial hypertension still have uncontrolled blood pressure, despite maximum doses of three antihypertensive drugs (including a diuretic) and appropriate lifestyle measures. New treatment modalities (i.e. devicebased interventions - catheter-based renal denervation and baroreceptor stimulation) offer hope for achieving adequate blood pressure regulation in these patients. In this paper, we have summarized previous knowledge about the mechanisms underlying the pathogenesis of resistant hypertension, as well as optimal diagnostic methods to differentiate true from pseudo-resistant hypertension. We have also given an overview of the current therapeutic approach, including optimal medical therapy and new treatment modalities (i.e. device-based interventions) and their role in the treatment of resistant hypertension.
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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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Vipparla N, Kichloo A, Albosta MS, Aljadah M, Wani F, Lone N. Resistant Hypertension Secondary to Severe Renal Artery Stenosis With Negative Duplex Ultrasound: A Brief Review of Different Diagnostic Modalities. J Investig Med High Impact Case Rep 2020; 8:2324709620914793. [PMID: 32202154 PMCID: PMC7092649 DOI: 10.1177/2324709620914793] [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] [Indexed: 11/20/2022] Open
Abstract
Renal artery stenosis is a cause of resistant hypertension, which can present with several features such as severe hypertension, deterioration of renal function (with or without associated angiotensin-converting inhibitor or angiotensin receptor blocker therapy), and flash pulmonary edema. When evaluating for the presence of renal artery stenosis, the most widely utilized imaging modalities are duplex ultrasonography and computed tomography angiography. In this article, we discuss the case of a 77-year-old female who presented with shortness of breath and mild pulmonary edema, secondary to hypertensive emergency. Later, she was diagnosed with renal artery stenosis and underwent stent placement in the left renal artery. Our case highlights the different diagnostic modalities and emphasizes that the most commonly used screening, which is duplex ultrasonography, was performed on our patient but gave a false-negative result, despite high-grade stenosis, which was later diagnosed on computed tomography angiography.
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Affiliation(s)
| | - Asim Kichloo
- St. Mary's of Saginaw Hospital, Saginaw, MI, USA.,Central Michigan University, Saginaw, MI, USA
| | | | | | - Farah Wani
- St. Mary's of Saginaw Hospital, Saginaw, MI, USA
| | - Nazir Lone
- Bassett Medical Center, Cooperstown, NY, USA
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Shibasaki S, Kishino T, Fujiwara Y, Suzuki Y, Harashima K, Nakajima S, Ohnishi H, Watanabe T. Influence of resting before sonographic examination on Doppler measurements of renal blood flow. Clin Physiol Funct Imaging 2020; 40:190-195. [PMID: 32092236 DOI: 10.1111/cpf.12625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 02/06/2020] [Accepted: 02/14/2020] [Indexed: 12/01/2022]
Abstract
Renal artery stenosis (RAS) is the most common cause of secondary hypertension, via increases in plasma renin-angiotensin-aldosterone levels. Renal artery stenosis is diagnosed from blood examinations such as renin activity and from imaging examinations such as sonography. Patients are required to lie on the bed for 30 min before and during phlebotomy, since plasma renin activity is easily altered by posture. However, no such pre-examination rest is required for sonography. The present study therefore investigated the possible influence of resting before examination on Doppler parameters used for the diagnosis of RAS. Subjects comprised 55 healthy young adults (24 males, 31 females; mean age, 22 ± 1 years). Sonographic measurements were made shortly after subjects entered the examination room and again after 30 min of rest lying on a bed. Median peak systolic velocity in the renal artery was significantly decreased after rest (106 cm/s, interquartile range (IQR) 96-121 cm/s) compared with before rest (120 cm/s, IQR 107-135 cm/s; p < .001). Median acceleration time in the intra-renal segmental artery was also significantly shorter after rest (49 ms, IQR 38-54 ms) compared to before rest (50 ms, IQR 38-59 ms; p = .039). The present results suggest that serious consideration should be given regarding whether pre-examination resting is needed to accurately interpret Doppler measurements of renal blood flow when diagnosing RAS from sonography.
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Affiliation(s)
| | | | | | - Yuka Suzuki
- Kyorin University Faculty of Health Sciences, Tokyo, Japan
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Reply. J Hypertens 2019; 37:454. [PMID: 30640879 DOI: 10.1097/hjh.0000000000001993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Kishino T, Harashima K, Hashimoto S, Fukuta N, Seki M, Ohnishi H, Watanabe T, Otaki J. Meal Ingestion and Hemodynamic Interactions Regarding Renal Blood Flow on Duplex Sonography: Potential Diagnostic Implications. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:2050-2054. [PMID: 30041904 DOI: 10.1016/j.ultrasmedbio.2018.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 05/13/2018] [Accepted: 05/16/2018] [Indexed: 06/08/2023]
Abstract
Splanchnic blood flow changes dramatically after meal ingestion. The present study evaluated physiologic interactions between meal ingestion and hemodynamics with respect to renal blood flow on duplex sonography, assessing the possible influence on Doppler parameters used as diagnostic criteria for renal artery stenosis. Subjects comprised 26 healthy young men (mean age: 22 ± 2 y). Sonographic measurements were made shortly after breakfast and every 1 h thereafter and were compared with values measured before the meal. Peak systolic velocity in the renal artery was elevated post-prandially, peaking at 1 h (90 ± 12 cm/s), compared with pre-prandially (73 ± 10 cm/s, p < 0.01). Similarly, acceleration time at the intra-renal segmental artery shortened to a minimum at 1 h (45 ± 5 ms) compared with baseline (51 ± 6 ms, p < 0.01). The present study indicates that renal blood flow is altered for a few hours after meal ingestion. Attention should be paid to the interpretation of data measured after meals on duplex sonography for diagnosis of renal artery stenosis.
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Affiliation(s)
- Tomonori Kishino
- Faculty of Health Sciences, Kyorin University, Tokyo, Japan; School of Medicine, Kyorin University, Tokyo, Japan.
| | | | | | - Naoya Fukuta
- Faculty of Health Sciences, Kyorin University, Tokyo, Japan
| | - Masayo Seki
- Faculty of Health Sciences, Kyorin University, Tokyo, Japan
| | | | | | - Junichi Otaki
- Faculty of Health Sciences, Kyorin University, Tokyo, Japan
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Stavropoulos K, Imprialos KP, Athyros VG, Doumas M. Renal resistive index for renovascular hypertension: In the quest of the Holy Grail. J Clin Hypertens (Greenwich) 2018; 20:589-591. [PMID: 29450962 PMCID: PMC8030749 DOI: 10.1111/jch.13221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Konstantinos Stavropoulos
- 2nd Propedeutic Department of Internal MedicineAristotle University of ThessalonikiThessalonikiGreece
| | - Konstantinos P. Imprialos
- 2nd Propedeutic Department of Internal MedicineAristotle University of ThessalonikiThessalonikiGreece
| | - Vasilios G. Athyros
- 2nd Propedeutic Department of Internal MedicineAristotle University of ThessalonikiThessalonikiGreece
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Boshra V, Abbas AM. Effects of peripherally and centrally applied ghrelin on the oxidative stress induced by renin angiotensin system in a rat model of renovascular hypertension. J Basic Clin Physiol Pharmacol 2018; 28:347-354. [PMID: 28315847 DOI: 10.1515/jbcpp-2016-0145] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 01/04/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Renovascular hypertension (RVH) is a result of renal artery stenosis, which is commonly due to astherosclerosis. In this study, we aimed to clarify the central and peripheral effects of ghrelin on the renin-angiotensin system (RAS) in a rat model of RVH. METHODS RVH was induced in rats by partial subdiaphragmatic aortic constriction. Experiment A was designed to assess the central effect of ghrelin via the intracerebroventricular (ICV) injection of ghrelin (5 μg/kg) or losartan (0.01 mg/kg) in RVH rats. Experiment B was designed to assess the peripheral effect of ghrelin via the subcutaneous (SC) injection of ghrelin (150 μg/kg) or losartan (10 mg/kg) for 7 consecutive days. Mean arterial blood pressure (MAP), heart rate, plasma renin activity (PRA), and oxidative stress markers were measured in all rats. In addition, angiotensin II receptor type 1 (AT1R) concentration was measured in the hypothalamus of rats in Experiment B. RESULTS RVH significantly increased brain AT1R, PRA, as well as the brain and plasma oxidative stress. Either SC or ICV ghrelin or losartan caused a significant decrease in MAP with no change in the heart rate. Central ghrelin or losartan caused a significant decrease in brain AT1R with significant alleviation of the brain oxidative stress. Central ghrelin caused a significant decrease in PRA, whereas central losartan caused a significant increase in PRA. SC ghrelin significantly decreased PRA and plasma oxidative stress, whereas SC losartan significantly increased PRA and decreased plasma oxidative stress. CONCLUSIONS The hypotensive effect of ghrelin is mediated through the amelioration of oxidative stress, which is induced by RAS centrally and peripherally.
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ACR Appropriateness Criteria® Renovascular Hypertension. J Am Coll Radiol 2017; 14:S540-S549. [DOI: 10.1016/j.jacr.2017.08.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 08/14/2017] [Indexed: 11/24/2022]
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Jacovic S, Zivkovic-Radojevic M, Petrovic D. Secondary Hypertension: Differential Diagnosis and Basic Principles of Treatment. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2016. [DOI: 10.1515/sjecr-2015-0056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Secondary hypertension occurs in 5-10% of cases in the patient population with primary hypertension. The most common forms of secondary hypertension are as follows: parenchymal renal disease (renoparenchymal hypertension), renal artery stenosis (renovascular hypertension), adrenal gland adenoma (primary hyperaldosteronism), a tumour of the adrenal gland marrow (pheochromocytoma) and adenoma of adrenal and pituitary glands (Cushing’s syndrome). In patients with a typical clinical picture of secondary hypertension, the appropriate diagnostic tests should be conducted based on the suspected form of secondary hypertension. Determining a diagnosis of secondary hypertension is gradual. First, the appropriate screening tests are performed. If the screening test is positive, then additional tests to confirm the forms of secondary hypertension are conducted. Once a diagnosis of the appropriate form of secondary hypertension is confirmed, tests to distinguish causes and laterality tests to determine the precise localisation of the pathological process are applied to evaluate the response to therapy. Analysing the results of endocrine diagnostic tests provides an accurate diagnosis and selection of optimal therapeutic procedures.
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Affiliation(s)
- Sasa Jacovic
- Medicines and Medical Devices Agency of Serbia, 458 Vojvode Stepe Street, 11221 Belgrade, Serbia
| | | | - Dejan Petrovic
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia Serbia
- Center of Nephrology and Dialysis, Department of Urology and Nephrology, Clinical Center Kragujevac, Kragujevac, Serbia
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17
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Petrovic D, Sreckovic M, Nikolic T, Zivkovic-Radojevic M, Miloradovic V. Renovascular Hypertension: Clinical Features, Differential Diagnoses and Basic Principles of Treatment. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2016. [DOI: 10.1515/sjecr-2016-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Renovascular hypertension is caused by renal artery stenosis. Its prevalence in populations of hypertensive patients is 1-8%, and in populations of patients with resistant hypertension, it is up to 20%. The two main causes of stenosis are atherosclerosis and fibromuscular dysplasia of the renal artery. The main clinical consequences of renal artery stenosis include renovascular hypertension, ischemic nephropathy and “flash” acute pulmonary oedema. Unilateral stenosis of the renal artery causes angiotensin II-dependent hypertension, and bilateral stenosis of the renal arteries produces volume-dependent hypertension. Renovascular aetiology of hypertension should be questioned in patients with resistant hypertension, hypertension with a murmur identified upon auscultation of the renal arteries, and a noticeable side-to-side difference in kidney size. Non-invasive diagnostic tests include the determination of concentrations of peripheral vein plasma renin activity, the captopril test, captopril scintigraphy, colour Doppler ultrasonography, computed tomography angiography, and nuclear resonance angiography. Renovasography represents the gold standard for the diagnosis of renovascular hypertension. The indications for revascularization of the renal artery include haemodynamically significant renal artery stenosis (with a systolic pressure gradient at the site of stenosis of - ΔP ≥ 20 mmHg, along with the ratio of the pressure in the distal part of the renal artery (Pd) and aortic pressure (Pa) less than 0.9 (Pd/Pa < 0.9)), resistant hypertension, loss of renal function after administration of ACE inhibitors or angiotensin receptor II blockers, and recurrent flash pulmonary oedema associated with bilateral renal artery stenosis. The contraindications for renal artery revascularization include a longitudinal diameter of the affected kidney that is less than 8.0 cm, the resistance index measured from the segmental arteries peak blood flow (RI) > 0.8, chronic kidney disease (GFR <30 ml/min/1.73 m2) and negative captopril scintigraphy (lack of lateralization).
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Affiliation(s)
- Dejan Petrovic
- Clinic for Urology and Nephrology, Clinical Center Kragujevac, Kragujevac
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Miodrag Sreckovic
- Clinic for Cardiology, Clinical Center Kragujevac, Kragujevac, Serbia
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Tomislav Nikolic
- Clinic for Urology and Nephrology, Clinical Center Kragujevac, Kragujevac
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | | | - Vladimir Miloradovic
- Clinic for Cardiology, Clinical Center Kragujevac, Kragujevac, Serbia
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
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Vakili H, Khaheshi I, Memaryan M, Sadeghi R, Naderian M. Resistant Hypertension due to Fibromuscular Dysplasia in a Young Male: A Rare Case Report. J Clin Diagn Res 2016; 10:OD08-9. [PMID: 27504335 DOI: 10.7860/jcdr/2016/20069.7938] [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: 03/11/2016] [Accepted: 04/19/2016] [Indexed: 11/24/2022]
Abstract
Fibromuscular Dysplasia (FMD) is a sporadic non-atherosclerotic disease. FMD has been established in nearly every arterial bed. However, the most frequent arteries affected are the renal and carotid arteries. Disease presentation may vary broadly, depending upon the arterial bed complication and the severity of illness. Hypertension, particularly resistant type, headache and dizziness are the most common presentations. String of beads appearance in angiographic views due to post-stenotic aneurysms is the characteristic view. It is most commonly described in young aged females; but in rare male cases has also been reported. Moreover, balloon angioplasty is standard and effective therapy for FMD. We present a young 28-year-old man who was referred for evaluation of resistant hypertension for nearly 3 years without comprehensive workup. The patient underwent renal artery angiography which confirmed beading narrowing of the right renal artery with significant stenosis at mid portion compatible with FMD; and balloon angioplasty was done. This case highlights that FMD should be kept in mind as a rare cause of resistant hypertension in young males; although it is most common in young females.
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Affiliation(s)
- Hossein Vakili
- Associate Professor, Department of Cardiology, Cardiovascular Research Center, Modarres Hospital, Shahid Beheshti University of Medical Sciences , Tehran, Iran
| | - Isa Khaheshi
- Assistant Professor, Department of Cardiology, Cardiovascular Research Center, Modarres Hospital, Shahid Beheshti University of Medical Sciences , Tehran, Iran
| | - Mehdi Memaryan
- Resident of Cardiology, Department of Cardiology, Cardiovascular Research Center, Modarres Hospital, Shahid Beheshti University of Medical Sciences , Tehran, Iran
| | - Roxana Sadeghi
- Associate Professor, Department of Cardiology, Cardiovascular Research Center, Shahid Beheshti University of Medical Sciences , Tehran, Iran
| | - Mohammadreza Naderian
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran, Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences , Tehran, Iran
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19
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Renovascular heart failure: heart failure in patients with atherosclerotic renal artery disease. Cardiovasc Interv Ther 2016; 31:171-82. [PMID: 27052017 DOI: 10.1007/s12928-016-0392-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 03/18/2016] [Indexed: 10/22/2022]
Abstract
Atherosclerotic renal artery disease presents with a broad spectrum of clinical features, including heart failure as well as hypertension, and renal failure. Although recent randomized controlled trials failed to demonstrate renal artery stenting can reduce blood pressure or the number of cardiovascular or renal events more so than medical therapy, increasing attention has been paid to flash pulmonary edema and congestive heart failure associated with atherosclerotic renal artery disease. This clinical entity "renovascular heart failure" is diagnosed retrospectively. Given the increasing global burden of heart failure, this review highlights the background and catheter-based therapeutic aspects for renovascular heart failure.
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Daidoji H, Tamada Y, Suzuki S, Watanabe K, Shikama T, Kikuchi Y, Kato S, Takahashi K, Fukui A, Matsui M, Yahagi T, Goto T. Plasma Renin Activity Predicts the Improvement in Resistant Hypertension after Percutaneous Transluminal Renal Artery Angioplasty. Intern Med 2016; 55:3421-3426. [PMID: 27904103 PMCID: PMC5216137 DOI: 10.2169/internalmedicine.55.7312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Objective Percutaneous transluminal renal artery angioplasty (PTRA) has been recommended for the treatment of renovascular resistant hypertension. However, large randomized trials have reported that PTRA did not improve the outcomes compared with optimal medical therapy in patients with renal artery stenosis (RAS). It is important to identify patients with renovascular hypertension who are likely to respond to PTRA. We herein examined whether or not the plasma renin activity (PRA) could predict the improvement in resistant hypertension after PTRA for RAS. Methods and Results A total of 40 patients (mean age: 63±15 years) with unilateral RAS who received PTRA for resistant hypertension were enrolled in this study. Twenty-two (55%) patients experienced a significant reduction in their blood pressure while using few antihypertensive agents at the 3-month follow up. The median PRA was significantly higher in patients using few antihypertensive agents than in those using more [4.2 ng/mL/hr, interquartile range (IQR) 2.6-8.0 vs. 0.8 ng/mL/hr, IQR 0.4-1.7, p<0.001]. To predict the improvement in hypertension after PTRA, a receiver operating characteristic analysis determined the optimal cut-off value of PRA to be 2.4 ng/mL/hr. A multivariate logistic regression analysis showed that higher PRA (>2.4 ng/mL/hr) was an independent predictor of the improvement in hypertension after PTRA (odds ratio: 22.3, 95% confidence interval: 2.17 to 65.6, p<0.01). Conclusion These findings suggest that the evaluation of preoperative PRA may be a useful tool for predicting the improvement in resistant hypertension after PTRA for patients with RAS.
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Affiliation(s)
- Hyuma Daidoji
- Department of Cardiology, Yamagata Prefectural Central Hospital, Japan
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21
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Woodley-Cook J, Konieczny M, Roche-Nagle G. Renal fibromuscular dysplasia. BMJ Case Rep 2015; 2015:bcr-2015-211973. [PMID: 26424827 DOI: 10.1136/bcr-2015-211973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Joel Woodley-Cook
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Magdalena Konieczny
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
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22
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Weber F, Anlauf M. Treatment resistant hypertension--investigation and conservative management. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:425-31. [PMID: 25008301 DOI: 10.3238/arztebl.2014.0425] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 04/07/2014] [Accepted: 04/07/2014] [Indexed: 01/25/2023]
Abstract
BACKGROUND The introduction of invasive treatments, some of which are irreversible, for the entity called treatment-resistant hypertension (TRH) creates the need for a comprehensive discussion of the diagnostic evaluation that TRH requires and the available options for its conservative treatment. METHOD The pertinent literature is selectively reviewed in the light of the authors' longstanding clinical experience. RESULTS Our review of the literature suggests that the high prevalence of TRH in Germany (ca. 20%) can be nearly halved with the aid of more thorough diagnostic evaluation. Such an evaluation should include a review of the patient's antihypertensive drugs (adherence, daily dosing, concomitant medication), investigation for other vascular changes that might affect blood pressure measurement, and exclusion of white-coat hypertension, sleep apnea syndrome, and secondary rather than essential hypertension. As there have been no randomized trials of treatment for TRH, the physician confronted with such cases must devise treatments on the basis of observational data and pathophysiological reasoning (volume status considering renin levels, sympathetic blockade, vasodilatation). Such measures can presumably lower the number of truly treatment-resistant cases still further. CONCLUSION To save patients from preventable harm, patients should undergo a thorough diagnostic evaluation and-under close monitoring for side effects-conservative pharmacological and nonpharmacological treatments should be deployed before any invasive treatment is performed.
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Affiliation(s)
- Franz Weber
- St Walburga Hospital, Meschede, Private Practice at the Medical Care Center, Dialysis Center, Cuxhaven
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23
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Chrysant SG. Treatment of hypertension in patients with atherosclerotic renal artery stenosis, updated. Postgrad Med 2015; 126:59-67. [PMID: 25387214 DOI: 10.3810/pgm.2014.11.2833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Atherosclerotic renal artery stenosis (ARAS) is a fairly common disease of elderly patients and is discovered incidentally in 6.3% to 38% in those undergoing diagnostic cardiac or abdominal angiography. Of those patients diagnosed with renal artery stenosis, in 90% it is due to ARAS and in 10% to fibromuscular dysplasia (FMD), which is a disease of younger persons, mostly females. Renal artery stenosis is frequently associated with hypertension and impaired renal function, and it is perceived by many physicians as the primary cause of hypertension and renal failure. For this reason, they believe that hypertension and renal failure can be significantly improved by performing percutaneous transluminal renal angioplasty (PTRA) with a stent placement as the preferred treatment instead of medical therapy. This practice has led to an increase in angioplasties, especially by interventional cardiologists who are familiar with the procedure. However, the results of several randomized studies comparing interventional therapy with medical therapy have shown no significant difference between the 2 treatment modalities in blood pressure reduction and prevention and in worsening of renal function. Similar results have been found by nonrandomized trials in patients treated selectively with PTRA. For this review, a Medline search was conducted of the English-language literature from January 1, 2006 to December 31, 2013, using the terms atherosclerotic renal artery stenosis and renal artery stenosis; 6 pertinent randomized studies were selected. These studies, with collateral literature, are discussed in this review. The data show that PTRA with stent plus medical therapy in patients with ARAS is not superior to medical therapy alone in lowering the blood pressure, in preventing renal function deterioration, and in reducing all-cause mortality, cardiovascular morbidity or mortality, and strokes.
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Affiliation(s)
- Steven G Chrysant
- Clinical Professor of Medicine University of Oklahoma College of Medicine, Oklahoma City, OK.
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24
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Pagliaro B, Tocci G, Pagannone E, Musumeci MB, Testa M, Sensini I, Autore C, Ferrucci A, Volpe M. An atypical clinical presentation of renovascular hypertension. Int J Cardiol 2014; 177:e107-10. [PMID: 25300660 DOI: 10.1016/j.ijcard.2014.09.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Accepted: 09/20/2014] [Indexed: 11/19/2022]
Affiliation(s)
- Beniamino Pagliaro
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome "Sapienza", Sant'Andrea Hospital, Rome, Italy
| | - Giuliano Tocci
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome "Sapienza", Sant'Andrea Hospital, Rome, Italy; IRCCS Neuromed, Pozzilli, IS, Italy
| | - Erika Pagannone
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome "Sapienza", Sant'Andrea Hospital, Rome, Italy
| | - M Beatrice Musumeci
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome "Sapienza", Sant'Andrea Hospital, Rome, Italy
| | - Marco Testa
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome "Sapienza", Sant'Andrea Hospital, Rome, Italy
| | - Isabella Sensini
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome "Sapienza", Sant'Andrea Hospital, Rome, Italy
| | - Camillo Autore
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome "Sapienza", Sant'Andrea Hospital, Rome, Italy
| | - Andrea Ferrucci
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome "Sapienza", Sant'Andrea Hospital, Rome, Italy
| | - Massimo Volpe
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome "Sapienza", Sant'Andrea Hospital, Rome, Italy; IRCCS Neuromed, Pozzilli, IS, Italy.
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25
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Martinelli O, Malaj A, Antignani PL, Frati G, Belli C, Venosi S, Irace L, Gossetti B, Gattuso R. Renal Stenting for Kidney Salvage in the Management of Renal Artery Atherosclerotic Stenosis. Angiology 2014; 66:785-91. [PMID: 25274528 DOI: 10.1177/0003319714553005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We studied the usefulness of preoperative resistance index to select patients who will benefit most from renal stenting. Sixty-two patients underwent renal stenting. All had chronic renal insufficiency with serum creatinine values ranging from 1.5 to 2.5 mg/dL and blood urea nitrogen between 80 and 107 mg/dL. All treated renal artery stenosis were >70%. Reduction in blood pressure in the early stages was observed in 39 (62.9%) patients; 31 (79.4%) patients returned to preoperative values within 12 months. A progressive reduction in creatinine values and blood urea nitrogen was reached in 43 (69.4%) patients, 12 (19.4%) patients remained unchanged, and the remaining 7 (11.2%) patients worsened. The best improvement in renal function was obtained in patients with a resistance index of ≤0.75 A preoperative resistance index up to 0.75 could be used as an indicator to predict which candidates will have improved renal function after stenting.
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Affiliation(s)
- O Martinelli
- Vascular Surgery, "Sapienza" University Rome, Rome, Italy
| | - A Malaj
- Vascular Surgery, "Sapienza" University Rome, Rome, Italy
| | - P L Antignani
- Department of Angiology, "San Giovanni Addolorata" Hospital, Rome, Italy
| | - G Frati
- Department of Biotechnology and Medical-Surgical Sciences, "Sapienza" University of Rome, Rome, Italy
| | - C Belli
- Vascular Surgery, "Sapienza" University Rome, Rome, Italy
| | - S Venosi
- Vascular Surgery, "Sapienza" University Rome, Rome, Italy
| | - L Irace
- Vascular Surgery, "Sapienza" University Rome, Rome, Italy
| | - B Gossetti
- Vascular Surgery, "Sapienza" University Rome, Rome, Italy
| | - R Gattuso
- Vascular Surgery, "Sapienza" University Rome, Rome, Italy
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26
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Kądziela J, Prejbisz A, Michałowska I, Adamczak M, Warchoł-Celińska E, Pregowska-Chwała B, Januszewicz M, Więcek A, Januszewicz A, Witkowski A. Relationship between hemodynamic parameters of renal artery stenosis and the changes of kidney function after renal artery stenting in patients with hypertension and preserved renal function. Blood Press 2014; 24:30-4. [DOI: 10.3109/08037051.2014.958304] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | | | - Marcin Adamczak
- Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland
| | | | | | | | - Andrzej Więcek
- Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland
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27
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Prigent A, Chaumet-Riffaud P. Clinical problems in renovascular disease and the role of nuclear medicine. Semin Nucl Med 2014; 44:110-22. [PMID: 24484748 DOI: 10.1053/j.semnuclmed.2013.10.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Although renovascular disease remains defined as a stenosis of the main renal artery or its proximal branches (renal artery stenosis [RAS]), its clinical overview has changed dramatically over the last 15-20 years and its management is more controversial than ever before. The clinical problems, not only diagnosis and treatment but also the relative contribution of different pathophysiological mechanisms involved in the progression of kidney disease, have shifted dramatically. This presentation aims to emphasize the paradigm change revisiting the (recent) past focused on renovascular hypertension (RVH) to the current context of preservation or recovery of threatened renal function in patients with progressive atherosclerotic renovascular disease until its last stage of irreversible "ischemic nephropathy." In the past, the foreground was occupied by RVH, a very rare disease, where the activation of the renin-angiotensin-aldosterone system (RAAS) was supposed to play the major, if not only, role in RVH issues. The retrospective RVH diagnosis was established either on the improvement or, more rarely, on the cure of hypertension after revascularization by, most often, a percutaneous transluminal renal angioplasty with or without a stent placement. At this time, captoptril radionuclide renography was an efficient diagnostic tool, because it was a functional (angiotensin-converting enzyme inhibition), noninvasive test aiming to evidence both the RAAS activation and the lateralization (or asymmetry) of renin secretion by the kidney affected by a "hemodynamically significant" RAS. At present, even if captoptril radionuclide renography could be looked upon as the most efficient (and cost effective in selected high-risk patients) noninvasive, functional test to predict the improvement of hypertension after RAS correction, its clinical usefulness is questioned as the randomized, prospective trials failed to demonstrate any significant benefits (either on blood pressure control or on renal function protection) of the revascularization over current antihypertensive therapy. Today many patients with RVH remain undetected for years because they are treated successfully and at low expense with these new blockers of RAAS. In addition to its well-known role in hemodynamics, angiotensin II promotes activations of profibrogenic and inflammatory factors and cells and stimulates reactive oxygen species generation. The "atherosclerotic milieu" itself plays a role in the loss of renal microvessels and defective angiogenesis. After an "adaptative" phase, ischemia eventually develops and induces hypoxia, the substratum of ischemic nephropathy. Because blood oxygen level-dependent MRI may provide an index of oxygen content in vivo, it may be useful to predict renal function outcome after percutaneous transluminal renal angioplasty. New PET tracers, dedicated to assess RAAS receptors, inflammatory cell infiltrates, angiogenesis, and apoptose, would be tested in this context of atherosclerotic renovascular disease.
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Affiliation(s)
- Alain Prigent
- Service de Biophysique et Médecine Nucléaire, AP-HP Hôpitaux Universitaires Paris-Sud Bicêtre, Paris, France.
| | - Philippe Chaumet-Riffaud
- Service de Biophysique et Médecine Nucléaire, AP-HP Hôpitaux Universitaires Paris-Sud Bicêtre, Paris, France; IR4M UMR8081 CNRS, Université Paris-Sud, Orsay, France
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29
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3D FIESTA pulse sequence for assessing renal artery stenosis: is it a reliable application in unenhanced magnetic resonance angiography? Eur Radiol 2014; 24:3042-50. [DOI: 10.1007/s00330-014-3330-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 06/18/2014] [Accepted: 07/08/2014] [Indexed: 10/25/2022]
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30
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Martinelli O, Malaj A, Gossetti B, Irace L. Stenting versus medical treatment for renal atherosclerotic artery stenosis. Angiology 2014; 66:201-3. [PMID: 24986513 DOI: 10.1177/0003319714540791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- O Martinelli
- Department of Vascular Surgery, Policlinico "Umberto I" Hospital, "Sapienza" University, Rome, Italy
| | - A Malaj
- Department of Vascular Surgery, Policlinico "Umberto I" Hospital, "Sapienza" University, Rome, Italy
| | - B Gossetti
- Department of Vascular Surgery, Policlinico "Umberto I" Hospital, "Sapienza" University, Rome, Italy
| | - L Irace
- Department of Vascular Surgery, Policlinico "Umberto I" Hospital, "Sapienza" University, Rome, Italy
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31
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Yoshihara T, Hasebe H, Shimasaki M, Uyama S, Takanohashi S, Togawa A, Takanohashi A, Shirota K, Nakamura H. Acute heart failure due to chronic juxtarenal aortic occlusion in a patient with antiphospholipid antibody syndrome. J Cardiol Cases 2014; 10:69-72. [PMID: 30546509 DOI: 10.1016/j.jccase.2014.05.004] [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: 01/14/2014] [Revised: 04/20/2014] [Accepted: 05/08/2014] [Indexed: 11/25/2022] Open
Abstract
Abdominal aortic occlusions are rare, but occasionally life threatening. A 48-year-old man was hospitalized due to acute heart failure accompanied by acute kidney injury (AKI). Abdominal ultrasound revealed deteriorating blood flow in the bilateral renal arteries. Subsequent abdominal aortography showed abdominal aortic occlusion just below the right renal artery and an occluded left renal artery. Dilated superior and inferior mesenteric arteries functioning as collateral feeding arteries suggested chronic occlusion. A hypercoagulation workup led to a diagnosis of antiphospholipid antibody syndrome (APS). This case report describes rare chronic juxtarenal abdominal occlusion in a patient with APS. <Leaning objective: Abdominal aortic occlusions are rare, but occasionally life threatening. The proximal propagation of aortic thrombosis might cause prerenal AKI. In our case, the renal arteries' involvement of chronic juxtarenal arteries in a patient with APS gave rise to the onset of acute heart failure associated with prerenal AKI.>.
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Affiliation(s)
- Tsutomu Yoshihara
- Division of Arrhythmology and Cardiology, Shizuoka Saiseikai General Hospital, Shizuoka, Japan
| | - Hideyuki Hasebe
- Division of Arrhythmology and Cardiology, Shizuoka Saiseikai General Hospital, Shizuoka, Japan
| | - Megumi Shimasaki
- Division of Nephrology, Shizuoka Saiseikai General Hospital, Shizuoka, Japan
| | - Satoko Uyama
- Division of Nephrology, Shizuoka Saiseikai General Hospital, Shizuoka, Japan
| | - Seiko Takanohashi
- Division of Nephrology, Shizuoka Saiseikai General Hospital, Shizuoka, Japan
| | - Akashi Togawa
- Division of Nephrology, Shizuoka Saiseikai General Hospital, Shizuoka, Japan
| | - Akira Takanohashi
- Division of Thoracic and Cardiovascular Surgery, Shizuoka Saiseikai General Hospital, Shizuoka, Japan
| | - Kazuaki Shirota
- Division of Thoracic and Cardiovascular Surgery, Shizuoka Saiseikai General Hospital, Shizuoka, Japan
| | - Hajime Nakamura
- Division of Thoracic and Cardiovascular Surgery, Shizuoka Saiseikai General Hospital, Shizuoka, Japan
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Abstract
The identification of primary aldosteronism as a common cause of resistant hypertension is a significant advance in our ability to care for patients with hypertension. Primary aldosteronism is common, and when unrecognized is associated with an increased incidence of adverse cardiovascular outcomes. Identification of primary aldosteronism is based on use of the plasma aldosterone level, plasma renin activity, and the aldosterone:renin ratio. Differentiation between unilateral and bilateral autonomous adrenal aldosterone production then guides further therapy, with use of mineralocorticoid-receptor blockers for patients with bilateral autonomous adrenal aldosterone production and laparoscopic adrenalectomy for patients with unilateral autonomous aldosterone production. In this review, we discuss in detail the pathogenesis of primary aldosteronism-induced hypertension and potassium disorders, the evaluation of the patient with suspected primary aldosteronism, and the management of primary aldosteronism, both through medications and surgery.
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Abstract
Radionuclide renal scintigraphy provides important functional data to assist in the diagnosis and management of patients with a variety of suspected genitourinary tract problems, but the procedures are underutilized. Maximizing the utility of the available studies (as well as the perception of utility by referring physicians) requires a clear understanding of the clinical question, attention to quality control, acquisition of the essential elements necessary to produce an informed interpretation, and production of a report that presents a coherent impression based on data contained in the report and that specifically addresses the clinical question. To help achieve these goals, part 1 of this review addressed the available radiopharmaceuticals, quality control, and quantitative indices, including the measurement of absolute and relative renal function. Part 2 assumes familiarity with part 1 and focuses on the common clinical indications of suspected obstruction and renovascular hypertension; part 2 also summarizes the status of radionuclide renal imaging in the evaluation of the transplanted kidney and the detection of infection, discusses potential pitfalls, and concludes with suggestions for future research. The series of SAM questions accompanying parts 1 and 2 has been designed to reinforce and extend points made in the review. Although the primary focus is the adult patient, aspects of the review also apply to the pediatric population.
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Affiliation(s)
- Andrew T Taylor
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
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Abstract
Secondary hypertension refers to arterial hypertension due to an identifiable cause and affects ∼5-10% of the general hypertensive population. Because secondary forms are rare and work up is time-consuming and expensive, only patients with clinical suspicion should be screened. In recent years, some new aspects gained importance regarding this screening. In particular, increasing evidence suggests that 24 h ambulatory blood pressure (BP) monitoring plays a central role in the work up of patients with suspected secondary hypertension. Moreover, obstructive sleep apnoea has been identified as one of the most frequent causes. Finally, the introduction of catheter-based renal denervation for the treatment of patients with resistant hypertension has dramatically increased the interest and the number of patients evaluated for renal artery stenosis. We review the clinical clues of the most common causes of secondary hypertension. Specific recommendations are given as to evaluation and treatment of various forms of secondary hypertension. Despite appropriate therapy or even removal of the secondary cause, BP rarely ever returns to normal with long-term follow-up. Such residue hypertension indicates either that some patients with secondary hypertension also have concomitant essential hypertension or that irreversible vascular remodelling has taken place. Thus, in patients with potentially reversible causes of hypertension, early detection and treatment are important to minimize/prevent irreversible changes in the vasculature and target organs.
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Affiliation(s)
- Stefano F Rimoldi
- Department of Cardiology, Inselspital, University Hospital, Bern, Switzerland
| | - Urs Scherrer
- Department of Cardiology, Inselspital, University Hospital, Bern, Switzerland Facultad de Ciencias, Departamento de Biología, Universidad de Tarapacá, Arica, Chile
| | - Franz H Messerli
- Division of Cardiology, St Luke's-Roosevelt Hospital Center, New York, NY, USA
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35
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How to distinguish between inconsistencies in CTA results and DSA findings. Herz 2013; 38:549-52. [DOI: 10.1007/s00059-012-3723-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 10/20/2012] [Indexed: 10/27/2022]
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36
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Ott C, Schneider MP, Schmieder RE. Ruling out secondary causes of hypertension. EUROINTERVENTION 2013; 9 Suppl R:R21-8. [DOI: 10.4244/eijv9sra5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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37
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Judd E, Lockhart ME, Rizk DV. Renovascular hypertension associated with pseudoaneurysm following blunt trauma. Am J Kidney Dis 2013; 62:839-43. [PMID: 23518197 DOI: 10.1053/j.ajkd.2012.12.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 12/18/2012] [Indexed: 11/11/2022]
Abstract
We present the case of a 21-year-old man who developed a renal artery pseudoaneurysm following a 7-foot fall onto his back. He initially presented with gross hematuria, left flank pain, and back pain. He was observed in the hospital for 3 days and discharged. One week later, he was readmitted with headache, nausea, vomiting, seizure activity, and hypertension. Contrast-enhanced computed tomography of the abdomen showed a left renal artery pseudoaneurysm with associated arterial narrowing and delayed ipsilateral renal enhancement. He underwent percutaneous stent-graft placement with resolution of the pseudoaneurysm. He was free of complications and normotensive off antihypertensive medications after 36 months of follow-up. Renal artery pseudoaneurysms are rare and under-recognized complications of blunt abdominal or back trauma that can cause hypertension. Imaging modalities in renovascular hypertension have focused on detecting renal artery stenosis from atherosclerotic disease or fibromuscular dysplasia, with little attention given to renal artery pseudoaneurysms. In addition, first-line treatment for renal artery pseudoaneurysms historically has consisted of angioembolization, yet percutaneous stent-graft placement has emerged as an attractive alternative to preserve vessel patency. We discuss the role of imaging in renovascular hypertension with a focus on renal artery pseudoaneurysms and their prevalence, diagnosis, and treatment.
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Affiliation(s)
- Eric Judd
- University of Alabama at Birmingham, Birmingham, AL.
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38
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González-Moreno J, Campins MA, Buades JM. Fibromuscular dysplasia presenting with asymptomatic bilateral renal infarctions. Int Urol Nephrol 2013; 46:243-6. [PMID: 23292597 DOI: 10.1007/s11255-012-0361-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 12/12/2012] [Indexed: 11/27/2022]
Abstract
Fibromuscular dysplasia (FMD) is a noninflammatory nonatherosclerotic vascular disease. It is the second cause of renovascular hypertension after atherosclerosis. Although FMD usually has a good prognosis, renal infarctions and artery dissections have been described. We present the case of a 38-year-old woman with hypertension and asymptomatic bilateral renal infarctions. Bilateral FMD of segmental branches of the renal arteries was diagnosed by digital subtraction angiography after an exhaustive study. Previous intake of nonsteroidal anti-inflammatory drugs may also have played a significant role in the development of renal infarctions. To our knowledge, bilateral renal infarctions complicating FMD have been reported in only four previous cases; only in one of those cases, renal infarctions were asymptomatic.
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Affiliation(s)
- J González-Moreno
- Internal Medicine Department, Hospital Son Llatzer, Palma de Mallorca, Spain,
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39
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Herrmann SMS, Textor SC. Diagnostic criteria for renovascular disease: where are we now? Nephrol Dial Transplant 2012; 27:2657-63. [PMID: 22802581 DOI: 10.1093/ndt/gfs254] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Renovascular disease, especially atherosclerotic renal artery stenosis (ARAS) in older subjects, is commonly encountered in clinical practice. This is at least in part due to the major advances in non-invasive imaging techniques that allow greater diagnostic sensitivity and accuracy than ever before. Despite increased awareness of ARAS, renal revascularization is less commonly performed, likely as a result of several prospective, randomized, clinical trials which fail to demonstrate major benefits of renal revascularization beyond medical therapy alone. Primary care physicians are less likely to investigate renovascular disease and nephrologists likely see more patients after a period of unsuccessful medical therapy with more advanced ARAS. The goal of this review is to revisit current diagnostic and therapeutic paradigms in order to characterize more clearly which patients will likely benefit from further evaluation and intensive treatment of renal artery stenosis.
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Geavlete O, Călin C, Croitoru M, Lupescu I, Ginghină C. Fibromuscular dysplasia--a rare cause of renovascular hypertension. Case study and overview of the literature data. J Med Life 2012; 5:316-20. [PMID: 23049635 PMCID: PMC3465001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Accepted: 08/15/2012] [Indexed: 11/09/2022] Open
Abstract
Renal artery stenosis (RAS) is associated with increased cardiovascular mortality and morbidity and may constitute a treatable cause of secondary hypertension. Fibromuscular dysplasia is frequently affecting children as the main cause of RAS, but is very rare in adults. We present the case of a 19-year-old overweight patient, with no known pathological conditions in her medical history or family background, admitted for severe, pulsing headaches during the past 3 months and increased blood pressure (BP) values for about a month (maximum BP 220/140 mmHg). The initial clinical exam and first-line imagistic methods did not provide a high suspicion for RAS. However, the invasive methods established the diagnosis of right renal artery medial dysplasia. Balloon angioplasty was the treatment of choice.
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Affiliation(s)
- O Geavlete
- Cardiology Department, “CC Iliescu” Institute of Cardiovascular Diseases, Bucharest, Romania
| | - C Călin
- Cardiology Department, “CC Iliescu” Institute of Cardiovascular Diseases, Bucharest, Romania
| | - M Croitoru
- Cardiology Department, “CC Iliescu” Institute of Cardiovascular Diseases, Bucharest, Romania
| | - I Lupescu
- Radiology and Imaging Departament, ”Fundeni” Hospital, Bucharest, Romania
| | - C Ginghină
- Cardiology Department, “CC Iliescu” Institute of Cardiovascular Diseases, Bucharest, Romania
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41
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Current world literature. Curr Opin Cardiol 2012; 27:441-54. [PMID: 22678411 DOI: 10.1097/hco.0b013e3283558773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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42
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Kotliar C, Juncos L, Inserra F, de Cavanagh EMV, Chuluyan E, Aquino JB, Hita A, Navari C, Sánchez R. Local and systemic cellular immunity in early renal artery atherosclerosis. Clin J Am Soc Nephrol 2012; 7:224-30. [PMID: 22193234 DOI: 10.2215/cjn.06270611] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2023]
Abstract
BACKGROUND AND OBJECTIVES Modern imaging techniques have increased the incidental detection of renal atherosclerotic disease (RAD). Because immune activation may hasten RAD progression, identifying cellular immune markers might provide clues to clinical activity. In this study, cellular immune markers were assessed in early RAD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Immune cell markers in peripheral blood of two groups of hypertensive patients with normal carotid and coronary arteries were evaluated: 28 patients had incidental RAD and 22 patients had normal renal arteries; 21 renal arteries obtained at necropsy from individuals with history of hypertension and tissue evidence of RAD were examined and matched with 21 individuals with normal renal arteries. Cell subpopulations were measured by flow cytometry in peripheral blood and direct cell count, respectively, using T and dendritic cells monoclonal antibodies. RESULTS Peripheral blood of RAD patients showed increased numbers of cells expressing CD3, CD4, CD83, and CD86. CD4 to CD8 ratio was 8.3 ± 1.4 (RAD) to 3.4 ± 0.9 (normal; P<0.001). No differences were found in CD25, CD8, and S100 among groups. Postmortem samples from RAD showed increased CD3+, CD4+, CD86+, and S100+ cells, whereas CD25+ and CD8+ were unmodified between groups. CD4+ to CD8+ ratio was higher in the RAD(PM) group. CONCLUSIONS These results are consistent with an increased expression of immune cell markers in early RAD. Additional studies will explore if they may potentially turn into treatment targets to prevent disease progression.
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Affiliation(s)
- Carol Kotliar
- Centro de Hipertensión Arterial, Servicio de Cardiología, Hospital Universitario Austral, Universidad Austral, Buenos Aires, Argentina.
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