To determine whether the type of renal artery stenosis and the rapid decline of renal function may have an impact on renal outcome after stenting.
Thirty patients with chronic kidney disease stages 3-4 and renal artery stenosis underwent stenting. The mean follow-up was 33 months; the change of estimated glomerular filtration rate was expressed as negative or positive value in mL/mo (ΔGFR). We identified two types of subgroups, on the basis of stenosis type: 1 (unilateral) N = 13 and 2 (7 bilateral, 2 single kidney, 8 prevalent kidney) N = 17; on the basis of declining ΔGFR in a pre-stenting period of 10 months: slow progressor (N = 11) and fast progressor (N = 13).
Thirty-seven stents were placed successfully. After stenting the median ΔGFR value was significantly greater in subgroup 2 compared with subgroup 1 (0.02 vs. -0.16; p = 0.02). Being in fast progressor and in subgroup 2 were associated with improved renal function after stenting (8 of 13 patients, p = 0.013; 11 of 17 patients, p = 0.032). In a logistic regression the only significant relationship is between improvement of renal function and rapid decline of pre-stenting GFR (odds ratio 16; p = 0.005).
The predictable benefit from renal stenting may be most likely in patients presenting with a rapid decline of GFR associated with renal artery stenosis affecting the whole renal mass that is both kidneys or single functioning kidney.
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to determine the incidence of and the risk factors associated with progression of renal artery disease in individuals with atherosclerotic renal artery stenosis (ARAS).
Subjects with >/=1 ARAS were monitored with serial renal artery duplex scans. A total of 295 kidneys in 170 patients were monitored for a mean of 33 months. Overall, the cumulative incidence of ARAS progression was 35% at 3 years and 51% at 5 years. The 3-year cumulative incidence of renal artery disease progression stratified by baseline disease classification was 18%, 28%, and 49% for renal arteries initially classified as normal, <60% stenosis, and >/=60% stenosis, respectively (P=0.03, log-rank test). There were only 9 renal artery occlusions during the study, all of which occurred in renal arteries having >/=60% stenosis at the examination before the detection of occlusion. A stepwise Cox proportional hazards model included 4 baseline factors that were significantly associated with the risk of renal artery disease progression during follow-up: systolic blood pressure >/=160 mm Hg (relative risk [RR]=2.1; 95% CI, 1.2 to 3.5), diabetes mellitus (RR=2.0; 95% CI, 1.2 to 3.3), and high-grade (>60% stenosis or occlusion) disease in either the ipsilateral (RR=1.9; 95% CI, 1.2 to 3.0) or contralateral (RR=1.7; 95% CI, 1.0 to 2.8) renal artery.
Although renal artery disease progression is a frequent occurrence, progression to total renal artery occlusion is not. The risk of renal artery disease progression is highest among individuals with preexisting high-grade stenosis in either renal artery, elevated systolic blood pressure, and diabetes mellitus.
[Show abstract][Hide abstract] ABSTRACT: Little is known about the efficacy and safety of renal artery stenting in patients with atherosclerotic renal artery stenosis (ARAS) and impaired renal function.
To determine the efficacy and safety of stent placement in patients with ARAS and impaired renal function.
Randomized clinical trial. Randomization was centralized and computer generated, and allocation was assigned by e-mail. Patients, providers, and persons who assessed outcomes were not blinded to treatment assignment.
10 European medical centers.
140 patients with creatinine clearance less than 80 mL/min per 1.73 m(2) and ARAS of 50% or greater.
Stent placement and medical treatment (64 patients) or medical treatment only (76 patients). Medical treatment consisted of antihypertensive treatment, a statin, and aspirin.
The primary end point was a 20% or greater decrease in creatinine clearance. Secondary end points included safety and cardiovascular morbidity and mortality.
Forty-six of 64 patients assigned to stent placement had the procedure. Ten of the 64 patients (16%) in the stent placement group and 16 patients (22%) in the medication group reached the primary end point (hazard ratio, 0.73 [95% CI, 0.33 to 1.61]). Serious complications occurred in the stent group, including 2 procedure-related deaths (3%), 1 late death secondary to an infected hematoma, and 1 patient who required dialysis secondary to cholesterol embolism. The groups did not differ for other secondary end points.
Many patients were falsely identified as having renal artery stenosis greater than 50% by noninvasive imaging and did not ultimately require stenting.
Stent placement with medical treatment had no clear effect on progression of impaired renal function but led to a small number of significant procedure-related complications. The study findings favor a conservative approach to patients with ARAS, focused on cardiovascular risk factor management and avoiding stenting.
Annals of internal medicine 06/2009; 150(12):840-8, W150-1. · 17.81 Impact Factor
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