Endovascular Management of Atherosclerotic Renal Artery Stenosis: Post-Cardiovascular Outcomes in Renal Atherosclerotic Lesions Era Winner or False Alarm?

Renovascular Hypertension in Chronic Hemodialytic Patient

Background: Hypertension is a major contributor to the development of chronic kidney disease. Data in Indonesia, hypertension is still the most comorbid disease in CKD patients on dialysis (51%). Hypertension in CKD on dialysis patients is common and often uncontrolled.  Renovascular hypertension is the most common cause of secondary hypertension. Diagnosis and treatment of RAS is very important, because it can accelerate the achievement of blood pressure targets, reduce the risk and complications due to hypertension. Case Report: A 52-year-old woman with CKD has been undergoing hemodialysis for 2 years. Hypertension that was previously well controlled for 2 years required an increase in antihypertensive therapy from 2 to 4 drugs in recent months. On physical examination the blood pressure 180/90 mmHg, pulse 79 bpm, respiration 20/min, temperature 36.7oC. Conjunctiva looks anemic, cardiomegaly, lungs within normal limits, no ascites and edema in the extremities. On renal artery duplex ultrasound examination, right main renal artery acceleration time 147.65 ms, Peak Systolic Velocity (PSV) 31.9 cm/s. RI 0.69 and left main renal artery acceleration time 120.81 ms, PSV 16.9 cm/s, RI 0.61. There was 20-30% left renal artery stenosis, 80% right renal artery stenosis. A stent was placed on the right renal artery. The patient's condition after PTRA improved, but at the next follow-up, mean systole and diastole 170 mmHg and 80 mmHg, respectively. Patient received 4 antihypertensive therapy. Conclusion: Renal artery stenosis is a disease that consists of a broad spectrum of different entities with different pathophysiologies that require varied approaches to diagnose and treat. Current diagnostic tools include MRA, CTA and renal artery duplex ultrasonography. Patients with renal parenchymal disease are poorer candidates for revascularization.

Effects of percutaneous angioplasty on kidney function and blood pressure in patients with atherosclerotic renal artery stenosis

Background

Previous randomized controlled trials of revascularization for atherosclerotic renal artery stenosis (ARAS) were not successful. We investigated the effects of percutaneous transluminal angioplasty with stent insertion (PTA/S) on kidney function and blood pressure (BP) control in patients with ARAS.

Methods

From 2000 to 2017, 47 subjects who underwent PTA/S for ARAS were identified. A high-risk group was defined, composed of patients having one or more of the following clinical presentations: pulmonary edema, refractory hypertension, and rapid deterioration of kidney function. Subjects who met the criteria of 'kidney function improvement' or 'hypertension improvement' after PTA/S were classified as responders.

Results

Twenty-one (44.7%) subjects were classified into the high-risk group. Two subjects (8.0%) in the low-risk group (n = 25) and 5 subjects (27.8%) in the high-risk group (n = 18) showed improvement in kidney function after PTA/S (P = 0.110). In patients with rapid decline of kidney function, estimated glomerular filtration rate improved from 28 (interquartile range [IQR], 10-45) mL/min/1.73 m² to 41 (IQR, 16-67) mL/min/1.73 m² at 4 months after PTA/S, although the difference was not significant (P = 0.084). Regarding BP control, 9 (36.0%) and 14 (77.8%) subjects showed improvement after PTA/S in the low- (n = 25) and high-risk (n = 18) groups, respectively (P = 0.007). In patients with refractory hypertension, the systolic BP dropped from 157 (IQR, 150-164) mmHg to 140 (IQR, 131-148) mmHg at 4 months after PTA/S (P = 0.005). Twenty-five subjects were defined as responders and comprised a significant proportion of the high-risk group (P = 0.004).

Conclusion

PTA/S might improve BP control and kidney function in patients with ARAS presenting with high-risk clinical features. The optimal application of PTA/S should be based on individual assessment of the clinical significance of renal artery stenosis.

[Can the pre-dialysis period in stage IV chronic kidney disease be prolonged?]

Analysed herein are the results of treating a total of 29 patients presenting with stage IV chronic kidney disease (CKD) induced by ischaemic nephropathy. All patients had renal artery stenosis more than 80%, decreased glomerular filtration rate (GFR) below 30 ml/min/1.73m2 and were regarded by the nephrologists as potential candidates for programmed haemodialysis. After preparation aimed at preventing contrast-induced nephropathy all patients underwent stenting of the stenosed renal arteries. In the early postoperative period, 21 patients were found to have stabilization of the GFR with a tendency to increase. One woman developed acute renal failure requiring renal replacement therapy by means of haemodialysis. During the follow-up period from 1 to 5 years, 26 patients showed no progression of azotemia. CKD changed to stage III in 15 patients (p<0.005). Twenty-three (84%) patients during the follow-up period developed no new cardiovascular events. Hence, performing renal revascularization for renal artery stenosis >80% revealed in patients with stage IV CKD promotes prolongation of the dialysis-free period.