Renal artery revascularization improves heart failure control in patients with atherosclerotic renal artery stenosis
Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA. Nephrology Dialysis Transplantation
(Impact Factor: 3.58).
09/2009; 25(3):813-20. DOI: 10.1093/ndt/gfp393
Renal artery stenosis (RAS) impacts the pathogenesis and control of heart failure (HF) and may further contribute to increased cardiovascular morbidity and mortality in HF patients. However, the long-term effects of renal artery revascularization on cardiovascular outcomes in HF patients are not well studied.
The prevalence of HF and its effects on all-cause mortality were studied in 163 consecutive patients with systemic hypertension and chronic kidney disease (serum creatinine >2 mg/dL) who underwent percutaneous transluminal renal angioplasty (PTRA) with stenting for atherosclerotic RAS. In addition, in 100 patients with RAS and coexistent HF, we compared the impact of medical treatment (n = 50) versus PTRA (n = 50) on clinical outcomes.
HF (predominantly normal ejection fraction) was present in 50/163 (31%) patients with systemic hypertension and chronic kidney disease (serum creatinine >2 mg/ dL) undergoing PTRA for RAS and represented the major predictor of all-cause mortality in these patients. When compared with sex-matched RAS and HF patients treated medically, PTRA with stenting was associated with a significant decrease in the New York Heart Association Functional Class (1.9 +/- 0.8 versus 2.6 +/- 1.0, P < 0.04) and a 5-fold reduction in the number of hospitalizations. However, renal artery revascularization did not impact mortality.
HF was present in one-third of patients with renal dysfunction and atherosclerotic RAS who were referred for PTRA. The presence of HF was associated with a significantly increased risk of death after PTRA with stenting. Renal artery revascularization resulted in improved HF control and a reduction in HF hospitalizations.
Available from: Carlo A Gaillard
- "In CHF, in several observational studies, patients with ARAS had prolonged hospital admissions and a higher mortality rate [8-10]. This finding is in agreement with reports that the presence of ARAS is associated with systemic atherosclerosis , reduced renal filtration and perfusion and with cardiac abnormalities. "
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ABSTRACT: Atherosclerotic renal artery stenosis (ARAS) is common in cardiovascular diseases and associated with hypertension, renal dysfunction and/or heart failure. There is a paucity of data about the prevalence and the role of ARAS in the pathophysiology of combined chronic heart failure (CHF) and chronic kidney disease (CKD). We investigated the prevalence in patients with combined CHF/CKD and its association with renal function, cardiac dysfunction and the presence and extent of myocardial fibrosis.
The EPOCARES study (ClinTrialsNCT00356733) investigates the role of erythropoietin in anaemic patients with combined CHF/CKD. Eligible subjects underwent combined cardiac magnetic resonance imaging (cMRI), including late gadolinium enhancement, with magnetic resonance angiography of the renal arteries (MRA).
MR study was performed in 37 patients (median age 74 years, eGFR 37.4 ± 15.6 ml/min, left ventricular ejection fraction (LVEF) 43.3 ± 11.2%), of which 21 (56.8%) had ARAS (defined as stenosis >50%). Of these 21 subjects, 8 (21.6%) had more severe ARAS >70% and 8 (21.6%) had a bilateral ARAS >50% (or previous bilateral PTA). There were no differences in age, NT-proBNP levels and medication profile between patients with ARAS versus those without. Renal function declined with the severity of ARAS (p = 0.03), although this was not significantly different between patients with ARAS versus those without. Diabetes mellitus was more prevalent in patients without ARAS (56.3%) against those with ARAS (23.8%) (p = 0.04). The presence and extent of late gadolinium enhancement, depicting myocardial fibrosis, did not differ (p = 0.80), nor did end diastolic volume (p = 0.60), left ventricular mass index (p = 0.11) or LVEF (p = 0.15). Neither was there a difference in the presence of an ischemic pattern of late enhancement in patients with ARAS versus those without.
ARAS is prevalent in combined CHF/CKD and its severity is associated with a decline in renal function. However, its presence does not correlate with a worse LVEF, a higher left ventricular mass or with the presence and extent of myocardial fibrosis. Further research is required for the role of ARAS in the pathophysiology of combined chronic heart and renal failure.
BMC Cardiovascular Disorders 09/2012; 12:76. DOI:10.1186/1471-2261-12-76 · 1.88 Impact Factor
- "The ASTRAL trial depicted that there is no significant difference between revascularization and medical therapy when taking in to account the rate of progression of renal impairment and the rates of new onset kidney injury, initiation of dialysis, renal transplantation, nephrectomy or death from renal failure and major cardiovascular events. One recent study showed that renal artery revascularization even resulted in improved control of heart failure and a reduction in hospitalizations secondary to it. These conflicting facts should not decrease the enthusiasm for intervention because such patients have greatest potential for absolute benefit from renal as well as cardiac point of view. "
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ABSTRACT: Renovascular disease (RVD) can present with resistant hypertension, acute or rapidly progressive renal failure and occasionally nephrotic proteinuria. Revascularization plays an important role in controlling blood pressure and preserving renal function. It is widely believed that delay in revascularization would result in irreversible loss of renal function. However, we report a favorable outcome despite delayed revascularization in two patients of RVD- one presenting with recurrent flash pulmonary edema and other with progressive renal failure. The former's serum creatinine returned to normal despite 3 months of anuria and the latter became dialysis-independent despite 2 months of progressive decline in renal function. Both remain dialysis-free 3 years after surgery.
Indian Journal of Nephrology 07/2012; 22(4):314-7. DOI:10.4103/0971-4065.101267
Telephone Energy conference, 1978. INTELEC 78. International; 11/1978
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