Long-Term Mortality After Renal Artery Stenting in Patients With Severe Atherosclerotic Renal Artery Stenosis and High-Risk Clinical Manifestations.

BACKGROUND: Atherosclerotic renal artery stenosis is a risk factor for cardiovascular death. Observational studies support the benefit of renal revascularization on outcomes in patients with high-risk clinical manifestations. In this context, we evaluated the factors associated with long-term mortality after renal artery stenting in patients with severe renal artery stenosis, impaired kidney function, and/or uncontrolled hypertension. METHODS: The medical records of patients undergoing renal artery stenting between 2004 and 2014 were extracted. Blood pressure and creatinine were recorded at baseline, 24 hours poststenting and in the 1-month to 1-year interval that followed revascularization. Long-term follow-up was performed in March 2020. RESULTS: The cohort consisted of 65 patients. Median follow-up was 120 months. In the first year after stenting, less patients had chronic kidney disease (CKD) class 3b-5 as compared with baseline (35.3% vs. 56.9%, P = 0.01). The number of patients with controlled blood pressure after revascularization increased with 69.2% (P < 0.001). Long-term all-cause mortality reached 44.6%. Age (odds ratio (OR) 1.1; 95% confidence interval (CI) 1.0-1.2; P = 0.01), male gender (OR 7.9; 95% CI 1.9-43.5; P = 0.008), poststenting CKD class 3b-5 (OR 5.8; 95% CI 1.5-27.9; P = 0.01), and postrevascularization uncontrolled hypertension (OR 8.9; 95% CI 1.7-63.5; P = 0.01) were associated with long-term mortality independent of diabetes mellitus and coronary artery disease. CONCLUSIONS: Improved CKD class and blood pressure were recorded in the first year after renal artery stenting in patients with severe renal artery stenosis and high-risk clinical manifestations. The lack of improvement in kidney function and blood pressure was independently associated with long-term mortality.

Clinical predictors of blood pressure response after renal artery stenting.

OBJECTIVE: The Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial, a multicenter randomized controlled trial, failed to demonstrate a benefit of renal artery stenting (RAS) over medical therapy in patients with renal artery stenosis and hypertension. However, there are patients for whom RAS is a consideration because of failure of medical therapy. Unfortunately, selection of patients for RAS is complicated by a lack of validated predictors of blood pressure (BP) response. A previous single-center study identified three preoperative markers of BP response to RAS: requirement for four or more antihypertensive medications, preoperative diastolic BP >90 mm Hg, and preoperative clonidine use. To date, these markers of outcome have not been independently validated. The aim of this study was to validate these markers using data from the CORAL trial. METHODS: All patients randomized in the CORAL trial to RAS were included. American Heart Association guidelines were used to categorize patients as BP responders or nonresponders to RAS. BP responders were defined by a postoperative BP <160/90 mm Hg with a reduced number of antihypertensive medications or a reduction in diastolic BP to <90 mm Hg with the same medications after RAS. Patients with stable or worsened BP were labeled nonresponders. Variables associated with a favorable BP response were identified by multivariable logistic regression analysis. RESULTS: There were 436 patients who underwent RAS with a median age of 70 years (interquartile range [IQR], 63-76 years). The median systolic and diastolic BPs of the stented cohort at baseline were 149 mm Hg (IQR, 132-164 mm Hg) and 78 mm Hg (IQR, 70-87 mm Hg), respectively. A positive BP response occurred in 284 of 436 (65.1%) stented patients. Multivariable logistic regression analysis identified three independent markers of a positive BP response: requirement for four or more medications (odds ratio, 5.9; P < .001), preoperative diastolic BP >90 mm Hg (odds ratio 13.9; P < .001), and preoperative clonidine use (odds ratio, 4.52; P = .008). The percentage of patients with a positive BP response increased incrementally as the number of markers per patient increased, based on the Cochran-Armitage test for trend (P < .0001). CONCLUSIONS: In patients from the CORAL trial who underwent RAS, the previously reported clinical markers of BP response were validated. A prospective trial to validate their utility as predictors of BP response to RAS is warranted.

Impact of Renal Function Trajectory on Renal Replacement Therapy and Mortality Risk after Renal Artery Revascularization.

PURPOSE: To determine the impact of renal function trajectory, defined as the change in renal function over time before and after renal artery stent placement, on long-term risk for renal replacement therapy (RRT) and mortality. MATERIALS AND METHODS: Estimated glomerular filtration rates (eGFRs) 6-12 months before renal artery stent placement, at the time of intervention, and 6-12 months after intervention were determined in 398 patients. The effect of eGFR change before and after renal artery stent placement was calculated. Cox proportional-hazards ratio was used to determine the risks for RRT and all-cause mortality. RESULTS: The risk for RRT was significantly influenced by eGFR change from the time of intervention to follow-up at 6-12 month after treatment (P = .02). In addition, among patients with a postintervention eGFR ≤ 40 mL/min/1.73 m2, for every 1 unit of eGFR increase, there was a significant decrease in RRT and all-cause mortality (P < .001 and P < .001, respectively). Secondary parameters that increased RRT risk included diabetes at the time of intervention (P = .03), increased baseline proteinuria (P < .001), and stage 4 or 5 chronic kidney disease (CKD; P = .01 and P = .003, respectively). Multivariate analysis demonstrated higher all-cause mortality rates among patients with diabetes at the time of intervention (P = .009). CONCLUSIONS: Postintervention eGFR trajectory improvement approaching 40 mL/min/1.73 m2 was associated with decreased RRT and mortality risk. These findings suggest that patients with advanced CKD and renal artery stenosis may benefit from revascularization regardless of their preinterventional renal function measurement.

OSTIAL VERSUS TRUNCAL RENAL ARTERY STENOSIS: PREDICTOR OF LARGE ARTERY ATHEROSCLEROSIS SEVERITY AND HIGHER MORTALITY.

The aim of this study was to determine arterial stiffness and the effect of stenting in patients with renal artery stenosis. We hypothesized that ostial renal artery stenosis is not only a marker of more pronounced atherosclerosis of large arteries, but is also a predictor of higher cardiovascular mortality. We enrolled 33 patients with renal artery stenosis refractory to pharmacological treatment and divided them according to the renal artery stenosis location, ostial and truncal (23 vs. 10 patients). We analyzed patient survival at five-year follow up. After the intervention and at six-month follow up, there was a significant decrease in blood pressure values, as well as in pulse wave velocity (PWV) and augmentation index. PWV was significantly lower in patients with truncal renal artery stenosis and these patients were significantly younger. Twelve patients with ostial and one patient with truncal renal artery stenosis (52% vs. 10%, p<0.001) died from cardiovascular events. Our study is the first to confirm the predictive role of PWV and arterial stiffness in patients with renal artery stenosis, especially ostial one, and to emphasize its ability of detecting future higher incidence of cardiovascular events.

Early Rapid Decline in Kidney Function in Medically Managed Patients With Atherosclerotic Renal Artery Stenosis.

Background Early rapid declines of kidney function may occur in patients with atherosclerotic renal artery stenosis with institution of medical therapy. The causes and consequences are not well understood. Methods and Results Patients enrolled in the medical therapy-only arm of the CORAL (Cardiovascular Outcomes With Renal Artery Lesions) study were assessed for a rapid decline (RD) in estimated glomerular filtration rate (eGFR), defined as a ≥30% decrease from baseline to either 3 months, 6 months, or both. In the medical therapy-only cohort, eGFR was available in 359 subjects at all time points, the subjects were followed for a median of 4.72 years, and 66 of 359 (18%) subjects experienced an early RD. Baseline log cystatin C (odds ratio, 1.78 [1.11-2.85]; P=0.02), age (odds ratio, 1.04 [1.00-1.07]; P<0.05), and Chronic Kidney Disease Epidemiology Collaboration creatinine eGFR (odds ratio, 1.86 [1.15-3.0]; P=0.01) were associated with an early RD. Despite continued medical therapy only, the RD group had an improvement in eGFR at 1 year (6.9%; P=0.04). The RD and nondecline groups were not significantly different for clinical events and all-cause mortality (P=0.78 and P=0.76, respectively). Similarly, renal replacement therapy occurred in 1 of 66 (1.5%) of the RD patients and in 6 of 294 (2%) of the nondecline patients. The regression to the mean of improvement in eGFR at 1 year in the RD group was estimated at 5.8±7.1%. Conclusions Early rapid declines in kidney function may occur in patients with renal artery stenosis when medical therapy is initiated, and their clinical outcomes are comparable to those without such a decline, when medical therapy only is continued.

Surgical Renovascular Reconstruction for Renal Artery Stenosis and Aneurysm: Long-Term Durability and Survival.

OBJECTIVE: To study functional outcome, mortality, and dialysis free survival in patients undergoing open primary surgical repair of renal artery stenosis (RAS) or aneurysm (RAA). METHODS: This was a retrospective single centre study of patients undergoing open surgical renal artery reconstruction from 1993 to 2007. Blood pressure, renal function, dialysis dependence, vessel patency, and mortality were registered. Survival was investigated by cross matching with the population registry, yielding up to 20 years of follow up. RESULTS: Of the 40 patients operated on, 25 (63%) were women. RAS was the indication for reconstruction in 31 patients; 23 had atherosclerotic aetiology (ARAS), and eight had fibromuscular dysplasia (FMD). Nine patients had RAA. Patients with ARAS were older (p = .008), had more extensive peripheral arterial disease (p = .004), and inferior renal function (p = .003) compared with patients with FMD or RAA. In FMD and RAA, the right renal artery was affected in 13/17 (76%) cases, whereas in ARAS the disease was evenly distributed. In patients with ARAS, 15/25 (60%) stenotic renal arteries (two bilateral procedures) were managed by aorto-renal bypass, and 2/25 (8%) through ilio-renal bypass. In 8/25 (32%) endarterectomy was performed. In FMD, all but one patient underwent aorto-renal bypass. Early mortality was 2.5% (one patient with ARAS). One patient with ARAS required dialysis post-operatively. Systolic blood pressure was significantly reduced in patients with ARAS, from 180 mmHg (median) pre-operatively to 155 mmHg at one month (p = .003) and 160 mmHg at one year (p = .03). Need for medication decreased from three or more drugs to two drugs at one month (p = .01). In FMD, there was a similar tendency. Three patients underwent re-intervention for restenosis: two endovascularly and one by open surgery. The overall 5 year survival was 88%. Median follow up was 10.6 years. CONCLUSION: Open surgical renal arterial reconstruction was performed with low mortality, fairly low morbidity, and excellent durability. Open surgery should still be considered a therapeutic option in complex renal artery disease.

Long-term Graft and Patient Survival after Percutaneous Angioplasty or Arterial Stent Placement for Transplant Renal Artery Stenosis: A 21-year Matched Cohort Study.

Purpose To compare long-term graft and patient survival after percutaneous angioplasty (PTA) or stent placement for transplant renal artery stenosis (TRAS) with a control cohort without TRAS. Materials and Methods This is a retrospective matched cohort study of 41 patients (median age, 49 years; range, 18-72 years), including 27 male patients (median age, 48 years; range, 18-67 years) and 14 female patients (median age, 52 years; range, 24-68 years), with TRAS from December 1995 through 2016. Primary end points were death-censored graft and patient survival, compared by using log-rank test and Cox proportional regression. Secondary outcomes were improvement in renal function, blood pressure (BP), and complications. Results Twenty-four patients underwent PTA and 17 received stent placements. Ten-year graft survival was 92.1% (range, 83.2%-100%) versus 81.4% (range, 67.8%-95.3%) (P = .56), and 10-year patient survival was 89.9% (79.1%-100%) versus 84.7% (72.1%-97.5%) (P = .49), for the study and control groups, respectively. Five patients (12%) resumed dialysis in each group and a total of 17 patients died (eight in the study group and nine in the control group). Most patients died with a functioning graft (seven of eight in the study group and seven of nine in the control group). Posttreatment median systolic and diastolic BP improved by 12% and 7.4%, respectively, and serum creatinine improved by 27%. Normal systolic BP and serum creatinine level at 1 year after treatment were associated with better survival for patients (P = .04; hazard ratio [HR], 1.04; 95% confidence interval [CI]: 1.0, 1.075) and grafts (P < .001; HR, 1.02; 95% CI: 1.0, 1.027). Other covariates, including PTA versus renal stent placement, intra-arterial pressure gradient greater than 10%, diastolic BP, age at transplantation, sex, graft type, rejection, and delayed graft function, were not significant. Five patients (12.2%) had a complication (Society of Interventional Radiology class A, two of 41 [4.9%]; class B, two of 41 [4.9%]; and class D, one of 41 [2.4%]); 30-day graft loss and patient mortality were zero. Conclusion Long-term graft and patient survival after endovascular correction of transplant renal artery stenosis (TRAS) was similar to that without TRAS and most patients avoided returning to dialysis. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by Dickey and Durrani in this issue.

Calcium channel blockers are associated with improved survival and lower cardiovascular mortality in patients with renovascular disease.

BACKGROUND AND OBJECTIVE: Results of interventional trials in renovascular hypertension have been disappointing, and medical therapy is the current recommended gold standard. However, the comparative long-term benefits of different antihypertensive drug classes in atherosclerotic renal artery stenosis are not known. We aim to assess the effect of different antihypertensive drug classes on outcomes in renovascular hypertension DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: Using Tayside Health Informatics Centre database, anonymized data over a 6-year period was analyzed. Biochemistry, prescribing data, morbidity, mortality, and demographic data were accessed via hospital medical records and electronic data stored in the Tayside Health Informatics Centre Safe Haven. General Registrar's Office data were used to identify patients who died from cardiovascular disease. Independent predictors of survival in each group were analyzed using Kaplan-Meier survival curves and Cox proportional hazard models, adjusted for a range of covariates, using time-updated drug analysis. Blood pressure data were obtained from primary and secondary care clinic blood pressure records for each patient. Adjustments for mean systolic blood pressure over the follow-up period and baseline blood pressure were made. RESULTS: A total of 579 patients with atherosclerotic renal artery stenosis were identified. In the unilateral renal artery stenosis cohort, calcium channel blockers but not ACE inhibitors/ARBs were associated with a significant reduction in all-cause (HR = 0.45, CI = 0.31, 0.65; P = <0.0001) and cardiovascular (HR = 0.51, CI = 0.29-0.90 P = 0.019) mortality. This was maintained after adjustment for blood pressure. In the bilateral renal artery stenosis cohort, both classes of drugs reduced all-cause but not cardiovascular mortality. Patients with moderate disease benefitted more than those with mild or severe disease. CONCLUSIONS: Calcium channel blockers are associated with significantly increased survival and lower cardiovascular mortality particularly in patients with moderate RAS disease.

Interaction between Albuminuria and Treatment Group Outcomes for Patients with Renal Artery Stenosis: The NITER Study.

PURPOSE: To perform a post-hoc analysis of the Nephropathy Ischemic Therapy (NITER) trial, which enrolled patients with atherosclerotic renal artery stenosis, to evaluate whether medical therapy plus stent placement is superior to medical therapy alone in patients without elevated albuminuria. MATERIALS AND METHODS: Data from 51 patients were analyzed and stratified into 2 cohorts by median urinary albumin (UAlb) levels: cohort 1 ("low albuminuria," UAlb ≤0.04 g/24h) and cohort 2 ("high albuminuria," UAlb >0.04g/24h). Interaction effect between treatment arms and UAlb cohorts was calculated using Cox regression analysis. Survival analysis was followed by test for effect size, power analysis, and construction of a Kaplan-Meier survival table. RESULTS: At study completion, 13 patients had an outcome event: 6 (23%) from cohort 1 and 7 (28%) from cohort 2. Patients in cohort 1 had event-free survival of 83% at 3.9 ± 0.3 years from the primary endpoints of all-cause mortality, dialysis, and cardiovascular events when treated with interventional therapy, compared to 45% when treated with medical therapy alone (P = .501), which showed a 62% treatment effect for stent placement. In cohort 2, event-free survival rates were 64% for medical therapy versus 52% for medical plus interventional therapy (P = .64). Using Cox regression analysis, the interaction effect between treatment arms and UAlb cohorts was not significant (P = .32). The power of the study to detect an interaction effect, if one existed, was only 15%. CONCLUSIONS: Inference cannot be drawn for similar populations because of inadequate sample size, but, in this sample, patients treated with stent placement who had low albuminuria had better outcomes than patients treated with medical therapy alone.

Revascularization of atherosclerotic renal artery stenosis for chronic heart failure versus acute pulmonary oedema.

AIM: The aim of the study is to determine whether the apparent benefit of revascularization of renal artery stenosis for 'flash' pulmonary oedema extends to heart failure patients without a history of prior acute pulmonary oedema. METHODS: A prospective study of patients with renal artery stenosis and heart failure at a single centre between 1 January 1995 and 31 December 2010. Patients were divided into those with and without previous acute pulmonary oedema/decompensation. Survival analysis compared revascularization versus medical therapy in each group using Cox regression adjusted for age, estimated glomerular filtration rate, blood pressure and co-morbidities. RESULTS: There were 152 patients: 59% male, 36% diabetic, age 70 ± 9 years, estimated glomerular filtration rate 29 ± 17 mL/min per 1.73 m2 ; 52 had experienced previous acute pulmonary oedema (34%), whereas 100 had no previous acute pulmonary oedema (66%). The revascularization rate was 31% in both groups. For heart failure without previous acute pulmonary oedema, the hazard ratio for death after revascularization compared with medical therapy was 0.76 (0.58-0.99, P = 0.04). In heart failure with previous acute pulmonary enema, the hazard ratio was 0.73 (0.44-1.21, P = 0.22). For those without previous acute pulmonary oedema, the hazard ratio for heart failure hospitalization after revascularization compared with medical therapy was 1.00 (0.17-6.05, P = 1.00). In those with previous acute pulmonary oedema, it was 0.51 (0.08-3.30, P = 0.48). CONCLUSION: The benefit of revascularization in heart failure may extend beyond the current indication of acute pulmonary oedema. However, findings derive from an observational study.

Predictors and Outcomes of Postcontrast Acute Kidney Injury after Endovascular Renal Artery Intervention.

PURPOSE: To determine incidence, predictors, and clinical outcomes of postcontrast acute kidney injury (PC-AKI) following renal artery stent placement for atherosclerotic renal artery stenosis. MATERIALS AND METHODS: This retrospective study reviewed 1,052 patients who underwent renal artery stent placement for atherosclerotic renal artery stenosis; 437 patients with follow-up data were included. Mean age was 73.6 years ± 8.3. PC-AKI was defined as absolute serum creatinine increase ≥ 0.3 mg/dL or percentage increase in serum creatinine ≥ 50% within 48 hours of intervention. Logistic regression analysis was performed to identify risk factors for PC-AKI. The cumulative proportion of patients who died or went on to hemodialysis was determined using Kaplan-Meier survival analysis. RESULTS: Mean follow-up was 71.1 months ± 68.4. PC-AKI developed in 26 patients (5.9%). Patients with PC-AKI had significantly higher levels of baseline proteinuria compared with patients without PC-AKI (odds ratio = 1.38; 95% confidence interval, 1.11-1.72; P = .004). Hydration before intervention, chronic kidney disease stage, baseline glomerular filtration rate, statin medications, contrast volume, and iodine load were not associated with higher rates of PC-AKI. Dialysis-free survival and mortality rates were not significantly different between patients with and without PC-AKI (P = .50 and P = .17, respectively). CONCLUSIONS: Elevated baseline proteinuria was the only predictor for PC-AKI in patients undergoing renal artery stent placement. Patients who developed PC-AKI were not at greater risk for hemodialysis or death.

A randomized, multi-center, prospective study comparing best medical treatment versus best medical treatment plus renal artery stenting in patients with hemodynamically relevant atherosclerotic renal artery stenosis (RADAR) - one-year results of a pre-maturely terminated study.

BACKGROUND: The indications for conservative "best medical treatment" (BMT) versus additional renal artery stenting are a matter of ongoing debate. The RADAR study aimed to evaluate the impact of percutaneous renal artery stenting on the impaired renal function in patients with hemodynamically significant atherosclerotic renal artery stenosis (RAS). METHODS: RADAR is an international, prospective, randomized (1:1) controlled study comparing BMT alone versus BMT plus renal artery stenting in patients with duplex sonographic hemodynamically relevant RAS. Follow-up assessments were at 2, 6, and 12 months and at 3 years. The primary endpoint was change in estimated glomerular filtration rate (eGFR) at 12 months. RESULTS: Due to slow enrollment, RADAR was terminated early after inclusion of 86 of the scheduled 300 patients (28.7%). Change in eGFR between baseline and 12 months was 4.3 ± 15.4 ml/min/1.73 m2 (stent group) and 3.0 ± 14.9 ml/min/1.73 m2 (BMT group), p > 0.999. Clinical event rates were low with a 12-month composite of cardiac death, stroke, myocardial infarction, and hospitalization for congestive heart failure of 2.9% in the stent and 5.3% in the BMT group, p = 0.526, and a 3-year composite of 14.8% and 12.0%, p = 0.982. At 3 years, target vessel (re-)vascularization occurred in one patient (3.0%) in the stent group and in 8 patients (29.4%) in the BMT group. CONCLUSION: In RADAR, outcomes of renal artery stenting were similar to BMT. These results have to be interpreted with the caveat that the study did not reach its statistically based sample size. TRIAL REGISTRATION: Clinicaltrials.gov, NCT00640406. Registered on 17 March 2008.

Renal Salvage with Renal Artery Stenting Improves Long-term Survival.

BACKGROUND: The Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) Trial cast doubt on the benefits of renal artery stenting (RAS). However, the outcomes for patients with chronic kidney disease (CKD) were not analyzed separately in the CORAL Trial. We hypothesized that patients who experienced a significant improvement in renal function after RAS would have improved long-term survival, compared with patients whose renal function was not improved by stenting. METHODS: This single-center retrospective study included 60 patients with stage 3 or worse CKD and renal artery occlusive disease who were treated with RAS for renal salvage. Patients were categorized as "responders" or "nonresponders" based on postoperative changes in estimated glomerular filtration rate (eGFR) after RAS. "Responders" were those patients with an improvement of at least 20% in eGFR over baseline; all others were categorized as "nonresponders." Survival was analyzed using the Kaplan-Meier method. Cox proportional hazards regression was used to identify predictors of long-term survival. RESULTS: The median age of the cohort was 66 years (interquartile range [IQR], 60-73). Median preoperative eGFR was 34 mL/min/1.73 m2 (IQR, 24-45). At late follow-up (median 35 months, IQR, 22-97 months), 16 of 60 patients (26.7%) were categorized as "responders" with a median increase in postoperative eGFR of 40% (IQR, 21-67). Long-term survival was superior for responders, compared with nonresponders (P = 0.046 by log-rank test). Cox proportional hazards regression identified improved renal function after RAS as the only significant predictor of increased long-term survival (hazard ratio = 0.235, 95% confidence interval = 0.075-0.733; P = 0.0126 for improved versus worsened renal function after RAS). CONCLUSIONS: Successful salvage of renal function by RAS is associated with improved long-term survival. These data provide an important counter argument to the prior negative clinical trials that found no benefit to RAS.

Concurrent renal artery stent during endovascular infrarenal aortic aneurysm repair confers higher risk for 30-day acute renal failure.

OBJECTIVE: Concurrent renal artery angioplasty and stenting (RAAS) during endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysm (AAA) has been practiced in an attempt to maintain renal perfusion. The aim of this study was to identify the current practice of RAAS during EVAR and its effect on perioperative renal outcome. METHODS: Patients with infrarenal AAA were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP, 2011-2014) database. Baseline characteristics of patients with concurrent RAAS during EVAR were compared with those of patients who underwent EVAR only. Bivariate and multivariable logistic regression analyses controlling for patients' demographics, comorbidities, and operative factors were used to evaluate the predictors of 30-day acute renal failure (ARF). Sensitivity analysis was done to evaluate the role of RAAS in patients with prior kidney disease. RESULTS: Overall, 6183 patients underwent EVAR for infrarenal AAA during the study period. Of them, 281 patients had RAAS during EVAR (4.5%). The median age of the patients was 74 years; 81.7% of the cohort was male, but a higher proportion of female patients received EVAR + RAAS compared with patients who underwent EVAR only (26.3% vs 17.9%; P < .001). There was no difference between groups in terms of comorbidities, being on dialysis, or functional status, yet the EVAR + RAAS group had a higher proportion of patients with glomerular filtration rate <60 mL/min/1.73 m2 (45.2% vs 37.2%; P = .011). RAAS was associated with significantly higher odds for development of ARF (adjusted odds ratio [aOR], 4.27; 95% confidence interval [CI], 2.06-8.84; P < .001). Other highly predictive factors of 30-day ARF were glomerular filtration rate <60 (aOR, 2.92; 95% CI, 1.47-5.78; P = .002), emergency status (aOR, 2.97; 95% CI, 1.21-7.27; P = .017), and ruptured AAA as the indication for EVAR (aOR, 4.74; 95% CI, 1.80-12.50; P = .002). Patients with prior kidney disease who had EVAR + RAAS demonstrated a 12-fold higher odds for 30-day ARF (aOR, 12.37; 95% CI, 4.66-32.89; P < .001). CONCLUSIONS: Concurrent RAAS was found to be a significant determinant of adverse renal outcomes after EVAR for infrarenal AAA. This effect was present even after controlling for patients' risk factors that might contribute to postoperative ARF.

Abordagem percutânea das doenças da artéria renal / Percutaneous approach to renal artery disease

A estenose da artéria renal (EAR) é uma importante causa de hipertensão arterial sistêmica (HAS) secundária e disfunção renal. O principal mecanismo é por doença aterosclerótica unilateral ou bilateral. O diagnóstico precoce é importante para se evitar falência renal terminal e graves complicações cardiovasculares. O início de HAS precoce ou tardia, sopros abdominais, déficit renal sem causa aparente e HAS resistente são achados clínicos para se suspeitar de EAR, sendo necessários exames complementares como o Doppler colorido, angiotomografia ou ressonância nuclear magnética das artérias renais. A arteriografia renal é o padrão ouro para confirmação diagnóstica. O tratamento medicamentoso está indicado para os pacientes assintomáticos ou que mantêm controle clínico satisfatórios. A intervenção percutânea da artéria renal com uso de stents tem sido motivo de controvérsia, ficando restrita aos pacientes com perda progressiva da função renal e estenose bilateral, hipertensão arterial resistente ao tratamento medicamentoso, edema agudo de pulmão hipertensivo de repetição e disfunção de enxerto renal no caso de pacientes submetidos ao transplante renal

Renal artery stenosis (RAS) is an important cause of secondary systemic hypertension and renal dysfunction. The main mechanism is unilateral or bilateral atherosclerotic disease. Early diagnosis is important to avoid terminal renal failure and severe cardiovascular complications. The onset of early or late secondary systemic hypertension, abdominal murmurs, renal failure without apparent cause, and resistant secondary systemic hypertension are clinical findings to suspect RAS, and complementary exams such as color Doppler, angiotomography or magnetic nuclear magnetic resonance imaging of the renal arteries are necessary. Renal arteriography is the gold standard for diagnostic confirmation. Drug treatment is indicated for patients who are asymptomatic or who maintain satisfactory clinical control. Percutaneous renal artery intervention with stents has been controversial, being restricted to patients with progressive renal function loss and bilateral stenosis, drug-resistant hypertension, acute repetitive hypertensive pulmonary edema and renal graft dysfunction in patients submitted to kidney transplant

Renal Artery Stenosis in Patients with Peripheral Artery Disease: Prevalence, Risk Factors and Long-term Prognosis.

OBJECTIVE/BACKGROUND: The objective was to determine the prevalence and clinical determinants of renal artery stenosis (RAS) in patients undergoing digital subtraction angiography (DSA) for the assessment of peripheral artery disease (PAD), and to evaluate its prognostic significance. METHODS: All DSAs performed from January 2000 to January 2006 were retrospectively reviewed for assessment of PAD in patients naive for any prior revascularisation of lower-limb arteries. All DSA studies were read by two senior physicians blinded to outcome, and consensus was reached in cases of disagreement. RAS was defined as the presence of ≥50% stenosis in either renal artery. Patients' electronic medical files were systematically reviewed and follow-up was completed by contact with family physicians until January 2014. The primary outcome was composite, including death, peripheral revascularisation, or any limb amputation. Secondary outcomes were all-cause mortality, and another composite, including death and non-fatal myocardial infarction or stroke or coronary or carotid revascularisation. RESULTS: In total, 400 consecutive patients having a first DSA of lower extremities, two thirds of whom were for critical limb ischaemia, were studied. Thirteen patients were excluded owing to poor renal artery imaging. RAS was detected in 57 patients (14%). Only two factors were independently and significantly associated with RAS in multivariate analysis: diffuse PAD (involving both proximal and distal segments [odds ratio {OR} 3.50, 95% confidence interval {CI} 1.16-10.54; p = .026]) and decreased glomerular filtration rate (OR 0.55 per 30 mL/minute/1.73 m2, 95% CI 0.41-0.75; p < .001). During follow-up (mean ± SD 62 ± 47 months), 25% experienced limb amputation and 54% died. In multivariate analysis, no significant association was found between RAS and primary outcome (hazard ratio 0.80; 95% CI 0.57-1.10). No significant association was found with secondary outcomes. CONCLUSION: Incidental RAS is frequent (14%) among patients with PAD undergoing lower extremity imaging. No difference in outcome in patients with RAS versus those without RAS was seen. Larger studies are necessary to draw definite conclusions.

Association of MYH9 rs3752462 and rs5756168 Polymorphisms With Transplanted Kidney Artery Stenosis.

Allelic variants of the MYH9 gene, encoding myosin nonmuscle heavy chain type IIA, have been shown to correlate with diminished glomerular filtration rates and end-stage kidney disease in individuals of Caucasian ancestry. Myosin nonmuscle heavy chain type IIA is expressed during development as well as in injured vessels and kidney structures. We hypothesized that MYH9 risk variants may correlate with kidney artery injury and dysfunctional healing, such as transplant renal artery stenosis (TRAS). Our study aimed at evaluating the association of MYH9 risk allelic variants (rs4821480, rs4821481, rs3752462, rs11089788, rs136211, rs5756168, rs2032487, and rs2239784) with TRAS, defined as >50% renal artery lumen reduction. Genotyping was performed with the use of custom Taqman genotyping assays on DNA samples (n = 295) from white deceased-donor kidney transplant recipients and genomic DNA from the corresponding donors. Statistical analysis was performed with the use of Kaplan-Meier estimates, log-rank tests, and proportional hazard Cox models. Recipients carrying TT in rs5756168 experienced diminished risk of TRAS (hazard ratio [HR], 0.31; P < .009), whereas organs carrying CC in rs3752462 were exposed to excessive TRAS risk (HR, 2.54; P < .047). In multivariate stepwise analysis TRAS was 10.9-fold increased in kidneys originating from rs3752462 CC, whereas the risk was decreased 3.45-fold (adjusted HR, 0.29) in recipients carrying rs5756168 TT (P < .007 and P < .033, respectively). Intracranial bleeding or trauma compared with other mechanisms of donor death diminished TRAS risk by 87% and 91%, respectively (P < .030 and P < .017). Our study is the first to identify genetic predisposition to transplant renal artery stenosis.

Comparative Effectiveness of Management Strategies for Renal Artery Stenosis: An Updated Systematic Review.

BACKGROUND: Atherosclerotic renal artery stenosis (ARAS) is associated with high blood pressure (BP), decreased kidney function, renal replacement therapy (RRT), and death. PURPOSE: To compare benefits and harms of percutaneous transluminal renal angioplasty with stent placement (PTRAS) versus medical therapy alone in adults with ARAS. DATA SOURCES: MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials from 1993 to 16 March 2016; gray literature; and prior systematic reviews. STUDY SELECTION: Randomized, controlled trials (RCTs); nonrandomized, comparative studies (NRCSs); single-group studies; and selected case reports that reported all-cause and cardiovascular mortality, RRT, kidney function, BP, and adverse events. DATA EXTRACTION: Six researchers extracted data on design, interventions, outcomes, and study quality into a Web-based database. DATA SYNTHESIS: Eighty-three studies met eligibility criteria. In 5 of 7 RCTs, PTRAS and medical therapy led to similar BP control in patients with ARAS, and no RCTs showed statistically significant differences in kidney function, mortality, RRT, cardiovascular events, or pulmonary edema. Eight NRCSs had more variable results, finding mostly no significant differences in mortality, RRT, or cardiovascular events but heterogeneous effects on kidney function and BP. Procedure-related adverse events were rare, and medication-related adverse events were not reported. Two RCTs found no patient characteristics that were associated with outcomes with either PTRAS or medical therapy. Single-group studies found various but inconsistent factors that predict outcomes. Case reports provided examples of clinical improvement after PTRAS in patients with acute decompensation. LIMITATION: Limited clinical applicability and power in RCTs, and possible publication bias and lack of adjusted analyses in NRCSs. CONCLUSION: The strength of evidence regarding the relative benefits and harms of PTRAS versus medical therapy alone for patients with ARAS is low. Studies have generally focused on patients with less severe ARAS. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Clinical characteristics and treatment of renal artery fibromuscular dysplasia with percutaneous transluminal angioplasty: a long-term follow-up study.

BACKGROUND: Renal artery fibromuscular dysplasia (RAFMD) is a non-atherosclerotic cause of renal artery stenosis often affecting the young. Percutaneous transluminal renal angioplasty (PTRA) is the treatment of choice but there are few studies of the outcome of the procedure. METHODS: This retrospective analysis included 64 patients (56.2 % female; mean age at diagnosis, 28.0 years) with RAFMD who underwent PTRA between November 2003 and August 2015. Technical and clinical success rates and restenosis rates were evaluated. RESULTS: Seventy-six procedures were performed on 64 RAFMD patients. Technical success was 96.9 %, as defined by <30 % residual stenosis, with stent placement required in 11 patients (17.2 %). In the short term (1 month), the majority (79.7 %) had an immediate clinical benefit, with cure of hypertension in 35.9 %, and improvement in hypertension and a lower requirement for antihypertensive medications in 43.8 %. In the long term (mean, 47.5 months; range, 5-141 months), the survival rate was 96.9 %, freedom from restenosis was 84.4 %, and 76.6 % of patients showed a sustained clinical benefit (cure rate 40.6 %, improvement rate 35.9 %). Eight patients were treated with a second procedure and two had a third procedure, with half of these patients showing an improvement in hypertension. CONCLUSION: PTRA for symptomatic RAFMD is safe and clinically successful. More than half of patients experience an immediate clinical benefit with sustained long-term effects. For patients with restenosis, there was a good response to a second PTRA.

Mortality and Renal Replacement Therapy after Renal Artery Stent Placement for Atherosclerotic Renovascular Disease.

PURPOSE: To identify risk factors for progression to renal replacement therapy (RRT) and all-cause mortality in patients who underwent renal artery (RA) stent placement for atherosclerotic renal artery stenosis (RAS). MATERIALS AND METHODS: A retrospective study from June 1996 to June 2009 identified 1,052 patients who underwent RA stent placement. Glomerular filtration rate at time of RA stent placement was estimated from serum creatinine level and divided into chronic kidney disease (CKD) stages 1-5. Univariate and multivariable Cox proportional hazards models were used to determine which factors were associated with each endpoint. RESULTS: Times to progression to all-cause mortality and RRT were similar for CKD stages 1/2/3A and served as the reference group. In multivariable analysis, high-grade proteinuria (P < .001) and higher CKD stage (5 vs 1/2/3A [P < .001], 4 vs 1/2/3A [P < .001], 3B vs 1/2/3A [P = .02]) remained independently associated with increased risk of progression to RRT. Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) use was associated with decreased risk of progression to RRT (P = .03). Higher CKD stage (5 vs 1/2/3A [P < .001], 4 vs 1/2/3A [P = .004]), carotid artery disease (P < .001), diabetes mellitus (P = .002), and high-grade proteinuria (P < .001) remained independently associated with all-cause mortality. Statin use was associated with decreased risk of all-cause mortality (P < .001). CONCLUSIONS: Patients with atherosclerotic RAS who undergo RA stent placement and have high-grade proteinuria and CKD stage 3B/4/5 have increased risk of progression to RRT. Patients with high-grade proteinuria, CKD stage 3B/4/5, carotid artery disease, or diabetes have increased risk for all-cause mortality after renal artery stent placement. Patients receiving ACEI/ARBs have a decreased risk of progression to RRT, and patients receiving statins have a decreased risk of all-cause mortality.