Different outcomes of atherosclerotic renal artery stenosis managed with stenting: results from a cohort study.
ABSTRACT 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.
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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. · 16.10 Impact Factor
- Cleveland Clinic Journal of Medicine 03/2010; 77(3):164-71. DOI:10.3949/ccjm.77a.10001 · 3.37 Impact Factor
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ABSTRACT: Stent revascularization is perceived as superior to balloon angioplasty and surgical revascularization, but the paucity of stent publications precludes even historical comparison with surgical data. Palmaz-Schatz stent revascularization of renal artery stenosis was successfully performed on 163 consecutive patients for poorly controlled hypertension or preservation of renal function. Of these, 145 were eligible for > or =6-month clinical follow-up of the effect of the procedure on renal function, blood pressure control, number of antihypertensive medications, and survival. At 4 years, systolic and diastolic blood pressures significantly decreased (from 166+/-26 to 148+/-22 mm Hg and from 86+/-14 to 80+/-11 mm Hg, respectively; P<0.05), and blood pressure control was more facile in approximately half of the patients. Creatinine decreased or remained stable in approximately two thirds of the patients. The cumulative probability of survival was 74+/-4% at 3 years, with few deaths related to end-stage renal disease. Survival was good in patients with normal (92+/-4%) baseline renal function, fair (74+/-7%) in those with mildly impaired renal function, and poor (52+/-7%) in patients with elevated baseline creatinine levels (> or =2.0 mg/dL). The combination of impaired renal function and bilateral disease adversely affected survival. Renal artery stent revascularization in the presence of normal or mildly impaired renal function had a beneficial effect on blood pressure control and a nondeleterious effect on renal function. Survival was adversely affected by renal dysfunction despite adequate revascularization. Early diagnosis and adequate revascularization before the onset of renal dysfunction could beneficially affect blood pressure control, preserve or prevent deterioration of renal function, and improve patient survival.Circulation 08/1998; 98(7):642-7. DOI:10.1161/01.CIR.98.7.642 · 14.95 Impact Factor