Fibromuscular dysplasia of the renal arteries: what do we know in 2024? / Dysplasie fibromusculaire des artères rénales : que savons-nous en 2024 ?

Fibromuscular dysplasia (FMD) is a rare nonatherosclerotic, noninflammatory vascular disease affecting mostly renal and carotid arteries and is the second most frequent cause of renal artery stenosis. The symptomatology is dominated by arterial hypertension due to the frequent involvement of the renal arteries and depends on the location of the lesions. Most of the cases are middle-aged women of Caucasian origin. There are two subtypes based on angiographic aspect: multifocal FMD (80% of the cases) and focal FMD (rarer with a more balanced sex ratio). Angioplasty of the renal arteries is generally disappointing with less than 50% cure of hypertension. It appears necessary to improve our knowledge of the FMD and to optimize the selection of eligible patients for revascularization with transdisciplinary collegial therapeutic decision.

La dysplasie fibromusculaire (DFM) est une maladie rare caractérisée par des sténoses segmentaires non artérioscléreuses, non inflammatoires, des artères de moyens calibres, touchant surtout les artères rénales et les carotides. Elle constitue la seconde cause de sténoses des artères rénales. La symptomatologie dépend de la localisation des lésions et est dominée par l'hypertension artérielle (HTA) en raison de l'atteinte fréquente des artères rénales. Cette pathologie touche majoritairement les femmes caucasiennes d'âge moyen. Il en existe deux sous-types, basés sur l'aspect angiographique : la DFM multifocale (80 % des cas) et la DFM focale (plus rare, sex ratio plus équilibré). Les résultats des prises en charge interventionnelle s'avèrent globalement décevants avec moins de 50 % de guérison de l'HTA. Il est nécessaire d'améliorer nos connaissances sur la physiopathologie de la DFM et d'optimiser la sélection des patients éligibles à une revascularisation par une prise de décision thérapeutique collégiale, en réunion de concertation pluridisciplinaire.

Doppler Ultrasound of the Renal Vasculature.

Ultrasound is the first-line imaging modality used in patients with suspected renovascular disease. Common indications include renovascular hypertension and unexplained renal dysfunction. We review the ultrasound imaging findings of various pathologies involving the renal vessels, including the renal arteries (atherosclerotic stenosis, fibromuscular dysplasia, dissection, arteriovenous fistula, and aneurysm) and veins (tumor and bland thrombus as well as vascular compression syndromes). The current role of renal artery stent placement for atherosclerotic stenosis is also discussed.

Improving outcomes in atherosclerotic renovascular disease: importance of clinical presentation and multi-disciplinary review.

BACKGROUND AND OBJECTIVES: Atherosclerotic renal artery stenosis may cause hypertension, chronic kidney disease and heart failure, but large randomized control trials to date have shown no major additional benefit of renal revascularization over optimal medical management. However, these trials did not consider outcomes specifically in relation to clinical presentations. Given that atherosclerotic renal artery stenosis is a heterogenous condition, measures of success likely differ according to the clinical presentation. Our retrospective study objectives were to determine the effects of revascularization when applied to specific clinical presentations and after careful multi-disciplinary team review. METHODS: All patients presenting to our centre and its referring hospitals with radiological findings of at least one renal artery stenosis > 50% between January 2015 and January 2020 were reviewed at the renovascular multi-disciplinary team meeting with revascularization considered in accordance with international guidelines, notably for patients with anatomically significant renal artery stenosis, adequately sized kidney and presentations with any of; deteriorating kidney function, heart failure syndrome, or uncontrollable hypertension. Optimal medical management was recommended for all patients which included lipid lowering agents, anti-platelets and anti-hypertensives targeting blood pressure ≤ 130/80 mmHg. The effect of revascularization was assessed according to the clinical presentation; blood pressure and number of agents in those with renovascular hypertension, delta glomerular filtration rate in those with ischaemic nephropathy and heart failure re-admissions in those with heart failure syndromes. RESULTS: During this 5-year period, 127 patients with stenosis ≥ 50% were considered by the multidisciplinary team, with 57 undergoing revascularization (17 primarily for severe hypertension, 25 deteriorating kidney function, 6 heart failure syndrome and 9 for very severe anatomical stenosis). Seventy-nine percent of all revascularized patients had a positive outcome specific to their clinical presentation, with 82% of those with severe hypertension improving blood pressure control, 72% with progressive ischaemic nephropathy having attenuated GFR decline, and no further heart failure admissions in those with heart failure. Seventy-eight percent of patients revascularized for high grade stenosis alone had better blood pressure control with 55% also manifesting renal functional benefits. CONCLUSIONS: Multi-disciplinary team discussion successfully identified a group of patients more likely to benefit from revascularization based on 3 key factors: clinical presentation, severity of the renal artery lesion and the state of the kidney beyond the stenotic lesion. In this way, a large proportion of patients can clinically improve after revascularization if their outcomes are considered according to the nature of their clinical presentation.

A Non-Coronary, Peripheral Arterial Atherosclerotic Disease (Carotid, Renal, Lower Limb) in Elderly Patients-A Review: Part I-Epidemiology, Risk Factors, and Atherosclerosis-Related Diversities in Elderly Patients.

Atherosclerosis is a generalized and progressive disease. Ageing is a key risk factor for atherosclerosis progression that is associated with the increased incidence of ischemic events in supplied organs, including stroke, coronary events, limb ischemia, or renal failure. Cardiovascular disease is the leading cause of death and major disability in adults ≥ 75 years of age. Atherosclerotic occlusive disease affects everyday activity and quality of life, and it is associated with reduced life expectancy. Although there is evidence on coronary artery disease management in the elderly, there is insufficient data on the management in older patients presented with atherosclerotic lesions outside the coronary territory. Despite this, trials and observational studies systematically exclude older patients, particularly those with severe comorbidities, physical or cognitive dysfunctions, frailty, or residence in a nursing home. This results in serious critical gaps in knowledge and a lack of guidance on the appropriate medical treatment and referral for endovascular or surgical interventions. Therefore, we attempted to gather data on the prevalence, risk factors, and management strategies in patients with extra-coronary atherosclerotic lesions.

A Non-Coronary, Peripheral Arterial Atherosclerotic Disease (Carotid, Renal, Lower Limb) in Elderly Patients-A Review PART II-Pharmacological Approach for Management of Elderly Patients with Peripheral Atherosclerotic Lesions outside Coronary Territory.

BACKGROUND: Aging is a key risk factor for atherosclerosis progression that is associated with increased incidence of ischemic events in supplied organs, including stroke, coronary events, limb ischemia, or renal failure. Cardiovascular disease is the leading cause of death and major disability in adults ≥ 75 years of age. Atherosclerotic occlusive disease affects everyday activity, quality of life, and it is associated with reduced life expectancy. As most multicenter randomized trials exclude elderly and very elderly patients, particularly those with severe comorbidities, physical or cognitive dysfunctions, frailty, or residence in a nursing home, there is insufficient data on the management of older patients presenting with atherosclerotic lesions outside coronary territory. This results in serious critical gaps in knowledge and a lack of guidance on the appropriate medical treatment. In addition, due to a variety of severe comorbidities in the elderly, the average daily number of pills taken by octogenarians exceeds nine. Polypharmacy frequently results in drug therapy problems related to interactions, drug toxicity, falls with injury, delirium, and non-adherence. Therefore, we have attempted to gather data on the medical treatment in patients with extra-cardiac atherosclerotic lesions indicating where there is some evidence of the management in elderly patients and where there are gaps in evidence-based medicine. Public PubMed databases were searched to review existing evidence on the effectiveness of lipid-lowering, antithrombotic, and new glucose-lowering medications in patients with extra-cardiac atherosclerotic occlusive disease.

Estenosis arterial del injerto renal: evaluación de la incidencia mediante ecografía doppler, factores de riesgo y análisis de las complicaciones que pueden afectar a la supervivencia del injerto / Transplant renal artery stenosis: Study of incidence using doppler ultrasound, risk factors and analysis is effect in graft outcomes

Introducción y objetivos La estenosis de la arteria del injerto renal (EAR) es una complicación vascular del trasplante renal cuya incidencia estimada es del 13%, la cual puede causar hipertensión arterial refractaria, disfunción renal y muerte prematura en los receptores. Métodos Se realizó un estudio retrospectivo que incluyó a todos los pacientes sometidos a trasplante renal entre 2014 y 2020. Los pacientes fueron evaluados mediante ecografía doppler renal sistemática tras el trasplante. Para identificar los factores de riesgo independientes de la estenosis de la arteria renal tras el trasplante, realizamos un análisis multivariante. Resultados Se incluyeron 724 trasplantes renales, el 12% eran de donante vivo y el 88% de donante fallecido. La edad media en los receptores era de 54,8 años y en los donantes era de 53. Se diagnosticó estenosis de la arteria del injerto renal en 70 (10%) receptores, la mayoría durante los primeros 6 meses después de la intervención. El 51% de los pacientes con estenosis de la arteria del injerto renal se manejaron de manera conservadora. El análisis multivariante mostró que la diabetes mellitus, el rechazo del injerto, la resutura arterial y el índice de masa corporal del donante eran factores de riesgo independientes de estenosis de la arteria renal después del trasplante. La supervivencia de los injertos con estenosis de la arteria del injerto renal fue del 98% a los 6 meses y del 95% a los 2 años. Conclusiones El uso sistemático de la ecografía doppler en el período inmediatamente posterior al trasplante permitió diagnosticar un 10% de estenosis de la arteria del injerto renal en nuestra cohorte. A pesar de los factores de riesgo mencionados anteriormente, un seguimiento y tratamiento adecuados podrían reducir el riesgo de pérdida del injerto en pacientes con estenosis de la arteria del injerto renal. (AU)

Introduction and objectives Transplant renal artery stenosis (TRAS) is a vascular complication after kidney transplantation which estimated incidence is 13%. It could cause refractory arterial hypertension, kidney dysfunction and premature death in transplant recipients. Methods We carried out a retrospective study including every patient who underwent renal transplantation between 2014 and 2020. They were evaluated with a systematic post-transplant renal Doppler ultrasound. To identify independent risk factors for transplant renal artery stenosis we performed a multivariate analysis. Results Seven hundred twenty-four kidney transplants were included, 12% were living donors and 88% were deceased donors. The mean age was 54.8 in recipients and 53 in donors. Transplant renal artery stenosis was diagnosed in 70 (10%) recipients, the majority in the first 6 months after surgery. The 51% of patients with transplant renal artery stenosis were managed conservatively. The multivariate analysis showed diabetes mellitus, graft rejection, arterial resuture and donor body mass index as independent risk factors for transplant renal artery stenosis. Survival of the grafts with transplant renal artery stenosis was 98% at 6 months and 95% at two years. Conclusions The systematic performance of Doppler ultrasound in the immediate post-transplant period diagnosed 10% of transplant renal artery stenosis in our cohort. Despite the above risk factors, an adequate monitoring and treatment could avoid the increased risk of graft loss in patients with transplant renal artery stenosis. (AU)

Prevalence and Associated Factors of Atherosclerotic Plaque and Stenosis in Renal Arteries: A Community-Based Study.

The epidemiology of renal artery atherosclerosis in community populations is poorly documented. This study aimed to determine the prevalence of renal artery plaque (RAP) and atherosclerotic renal artery stenosis (ARAS), and the association of plaque and stenosis with vascular risk factors and kidney disease markers among community-dwelling adults. We conducted a cross-sectional analysis of the Polyvascular Evaluation for Cognitive Impairment and Vascular Events (PRECISE) study. RAP and ARAS were evaluated by thoracoabdominal computed tomography angiography. A total of 3045 adults aged 50-75 years were included. The prevalence of RAP and ARAS was 28.7% and 4.8%, respectively. The prevalence of RAP and ARAS was 41.3% and 7.7% in individuals aged ≥60 years, 42.9% and 8.7% in hypertensives, and 45.4% and 8.5% in individuals with chronic kidney disease. Older age, hypertension, higher total cholesterol level, and lower high-density lipoprotein cholesterol level were independently associated with RAP and ARAS. A higher urinary albumin-creatinine ratio was independently associated with RAP, whereas a reduced estimated glomerular filtration rate was independently associated with ARAS. In conclusion, there was a non-negligible prevalence of RAP and ARAS among the older, community population in China.

Intravascular ultrasound-guided, lithotrispy facilitated angioplasty for treating a heavily calcified renal artery stenosis.

A 63-year-old woman with uncontrolled hypertension despite taking 5 antihypertensive medications was referred for percutaneous renal artery intervention.

Deep-learning-based renal artery stenosis diagnosis via multimodal fusion.

PURPOSE: Diagnosing Renal artery stenosis (RAS) presents challenges. This research aimed to develop a deep learning model for the computer-aided diagnosis of RAS, utilizing multimodal fusion technology based on ultrasound scanning images, spectral waveforms, and clinical information. METHODS: A total of 1485 patients received renal artery ultrasonography from Peking Union Medical College Hospital were included and their color doppler sonography (CDS) images were classified according to anatomical site and left-right orientation. The RAS diagnosis was modeled as a process involving feature extraction and multimodal fusion. Three deep learning (DL) models (ResNeSt, ResNet, and XCiT) were trained on a multimodal dataset consisted of CDS images, spectrum waveform images, and individual basic information. Predicted performance of different models were compared with senior physician and evaluated on a test dataset (N = 117 patients) with renal artery angiography results. RESULTS: Sample sizes of training and validation datasets were 3292 and 169 respectively. On test data (N = 676 samples), predicted accuracies of three DL models were more than 80% and the ResNeSt achieved the accuracy 83.49% ± 0.45%, precision 81.89% ± 3.00%, and recall 76.97% ± 3.7%. There was no significant difference between the accuracy of ResNeSt and ResNet (82.84% ± 1.52%), and the ResNeSt was higher than the XCiT (80.71% ± 2.23%, p < 0.05). Compared to the gold standard, renal artery angiography, the accuracy of ResNest model was 78.25% ± 1.62%, which was inferior to the senior physician (90.09%). Besides, compared to the multimodal fusion model, the performance of single-modal model on spectrum waveform images was relatively lower. CONCLUSION: The DL multimodal fusion model shows promising results in assisting RAS diagnosis.

Magnetic Resonance Imaging in Atherosclerotic Renal Artery Stenosis: The Update and Future Directions from Interventional Perspective.

Background: Atherosclerotic renal artery stenosis (ARAS) is a condition where the renal arteries become narrowed due to atherosclerosis, leading to reduced blood flow to the kidneys and various renal complications. The effectiveness of interventional treatments, such as renal artery angioplasty and stenting, remains debated, making patient selection for these procedures challenging. Summary: This review focuses on the diagnosis and management of ARAS, with a particular emphasis on the potential role of functional magnetic resonance imaging (MRI) in evaluating renal function and mechanisms. By summarizing current diagnostic approaches and outcomes of interventional treatments, the review highlights the importance of informed clinical decision-making in ARAS management. Functional MRI emerges as a promising noninvasive tool to assess renal function, aiding in patient stratification and treatment planning. Key Messages: The efficacy of interventional treatments for ARAS requires further investigation and careful patient selection. Functional MRI holds promise as a noninvasive means to assess renal function and mechanisms, potentially guiding more effective clinical decisions in ARAS management. Advancing research in diagnostic methods, particularly functional MRI, can enhance our understanding and improve the treatment outcomes for ARAS patients.

Case report: Endovascular treatment of transplant renal artery stenosis in patient with normal color duplex ultrasound of the renal artery.

Key Clinical Message: Proper diagnosis and treatment of vascular stenosis which is a possible complication of renal transplant is important in improving patients' quality of life and prognosis. Abstract: One known consequence among recipients of renal transplants is graft renal artery stenosis. Early identification and therapy are crucial to avoid graft malfunction and the serious consequences that might arise due to elevated hypertension in several organs. We report a rare case of transplant renal artery stenosis in a mid-aged woman who presented with edema, hypertension, and increased creatinine 2 months after kidney transplant. The patient had normal renal arterial resistive index (RI) and perfusion index (PI), and there was only a modest decrease in perfusion on duplex ultrasound. Following the patient's renal stenting treatment, angiographic resolution was observed. After 14 days of regulated blood pressure following renal artery stenting, she was discharged from the hospital with her edema resolved. Considering complications in patients with clinical manifestations such as hypertension resistant to treatment and graft dysfunction, vascular stenosis is a notable issue to consider even in the context of normal renal arterial RI, PI, and duplex ultrasound. Proper diagnosis and treatment are of importance to improve patients' quality of life and prognosis.

Patterns of cortical oxygenation may predict the response to stenting in subjects with renal artery stenosis: A radiomics-based model.

BACKGROUND: Percutaneous-transluminal renal angioplasty (PTRA) and stenting aim to halt the progression of kidney disease in patients with renal artery stenosis (RAS), but its outcome is often suboptimal. We hypothesized that a model incorporating markers of renal function and oxygenation extracted using radiomics analysis of blood oxygenation-level dependent (BOLD)-MRI images may predict renal response to PTRA in swine RAS. MATERIALS AND METHODS: Twenty domestic pigs with RAS were scanned with CT and BOLD MRI before and 4 weeks after PTRA. Stenotic (STK) and contralateral (CLK) kidney volume, blood flow (RBF), and glomerular filtration rate (GFR) were determined, and BOLD-MRI R2 * maps were generated before and after administration of furosemide, a tubular reabsorption inhibitor. Radiomics features were extracted from pre-PTRA BOLD maps and Robust features were determined by Intraclass correlation coefficients (ICC). Prognostic models were developed to predict post-PTRA renal function based on the baseline functional and BOLD-radiomics features, using Lasso-regression for training, and testing with resampling. RESULTS: Twenty-six radiomics features passed the robustness test. STK oxygenation distribution pattern did not respond to furosemide, whereas in the CLK radiomics features sensitive to oxygenation heterogeneity declined. Radiomics-based model predictions of post-PTRA GFR (r = 0.58, p = 0.007) and RBF (r = 0.68; p = 0.001) correlated with actual measurements with sensitivity and specificity of 92% and 67%, respectively. Models were unsuccessful in predicting post-PTRA systemic measures of renal function. CONCLUSIONS: Several radiomics features are sensitive to cortical oxygenation patterns and permit estimation of post-PTRA renal function, thereby distinguishing subjects likely to respond to PTRA and stenting.

Percutaneous transluminal angioplasty with stenting for transplant renal artery stenosis at the anastomosis site in a young female patient: A case report.

INTRODUCTION: Transplant renal artery stenosis (TRAS) is one of the major vascular complications and is mostly reported within six months following kidney transplant. CASE PRESENTATION: The present case was a 16-year-old female whose blood urea nitrogen (BUN) and creatinine rose seven days after a kidney transplant. Ultrasound investigation revealed well-prefusion with a 90-degree angle anastomosis, apparent narrowing, and peak systolic velocity of 300 cm/s. Fourteen days after the transplant, with pre-and post-intervention hemodialysis and well hydration, an angiography with diluted iodinated contrast was done for the patient, which revealed >80 % narrowing at the anastomosis site. Percutaneous transluminal angioplasty (PTAS) with stenting was carried out for the patient, resulting in normal levels of BUN, creatinine, and urinary output. CLINICAL DISCUSSION: While the patient did not have any risk factors for TRAS and was young, an early stenosis occurred in her left internal iliac artery one week after the kidney transplant. Due to the lower accuracy of CO2 angiography, diluted iodinated contrast angiography with well hydration and pre- and post-intervention dialysis was preferred. Endovascular treatment was preferred by the patient and attending physician due to possible adhesion and complications of open surgery and the possibility of arterial rupture. CONCLUSION: Performing PTAS two weeks after the renal transplantation at the anastomosis site can be a treatment in patients with early TRAS. However, due to the higher risk of rupture at the anastomosis site, it should be carried out carefully and with consideration of the need for open surgery.

CT-based radiomics: predicting early outcomes after percutaneous transluminal renal angioplasty in patients with severe atherosclerotic renal artery stenosis.

This study aimed to comprehensively evaluate non-contrast computed tomography (CT)-based radiomics for predicting early outcomes in patients with severe atherosclerotic renal artery stenosis (ARAS) after percutaneous transluminal renal angioplasty (PTRA). A total of 52 patients were retrospectively recruited, and their clinical characteristics and pretreatment CT images were collected. During a median follow-up period of 3.7 mo, 18 patients were confirmed to have benefited from the treatment, defined as a 20% improvement from baseline in the estimated glomerular filtration rate. A deep learning network trained via self-supervised learning was used to enhance the imaging phenotype characteristics. Radiomics features, comprising 116 handcrafted features and 78 deep learning features, were extracted from the affected renal and perirenal adipose regions. More features from the latter were correlated with early outcomes, as determined by univariate analysis, and were visually represented in radiomics heatmaps and volcano plots. After using consensus clustering and the least absolute shrinkage and selection operator method for feature selection, five machine learning models were evaluated. Logistic regression yielded the highest leave-one-out cross-validation accuracy of 0.780 (95%CI: 0.660-0.880) for the renal signature, while the support vector machine achieved 0.865 (95%CI: 0.769-0.942) for the perirenal adipose signature. SHapley Additive exPlanations was used to visually interpret the prediction mechanism, and a histogram feature and a deep learning feature were identified as the most influential factors for the renal signature and perirenal adipose signature, respectively. Multivariate analysis revealed that both signatures served as independent predictive factors. When combined, they achieved an area under the receiver operating characteristic curve of 0.888 (95%CI: 0.784-0.992), indicating that the imaging phenotypes from both regions complemented each other. In conclusion, non-contrast CT-based radiomics can be leveraged to predict the early outcomes of PTRA, thereby assisting in identifying patients with ARAS suitable for this treatment, with perirenal adipose tissue providing added predictive value.

Renal artery involvement is associated with increased morbidity but not mortality in Takayasu arteritis: a matched cohort study of 215 patients.

BACKGROUND: We analyzed differences in presentation and survival of Takayasu arteritis (TAK) with or without renal artery involvement (RAI) from a large monocentric cohort of patients with TAK. METHODS: Clinical and angiographic features were compared between TAK with versus without RAI, with bilateral versus unilateral RAI, and with bilateral RAI versus without RAI using multivariable-adjusted logistic regression. Inter-group differences in survival were analyzed [hazard ratios (HR) with 95% confidence intervals (95%CI)] adjusted for gender, age at disease onset, diagnostic delay, baseline disease activity, and significant clinical/angiographic inter-group differences after multivariable-adjustment/propensity score matching (PSM). RESULTS: Of 215 TAK, 117(54.42%) had RAI [66(56.41%) bilateral]. TAK with RAI or with bilateral RAI had earlier disease onset than without RAI (p < 0.001). Chronic renal failure (CRF) was exclusively seen in TAK with RAI. TAK with RAI (vs without RAI) had more frequent hypertension (p = 0.001), heart failure (p = 0.047), abdominal aorta (p = 0.001) or superior mesenteric artery involvement (p = 0.018). TAK with bilateral RAI (vs unilateral RAI) more often had hypertension (p = 0.011) and blurring of vision (p = 0.049). TAK with bilateral RAI (vs without RAI) more frequently had hypertension (p = 0.002), heart failure (p = 0.036), abdominal aorta (p < 0.001), superior mesenteric artery (p = 0.002), or left subclavian artery involvement (p = 0.041). Despite higher morbidity (hypertension, CRF), mortality risk was not increased with RAI vs without RAI (HR 2.32, 95%CI 0.61-8.78), with bilateral RAI vs unilateral RAI (HR 2.65, 95%CI 0.52-13.42) or without RAI (HR 3.16, 95%CI 0.79-12.70) even after multivariable adjustment or PSM. CONCLUSION: RAI is associated with increased morbidity (CRF, hypertension, heart failure) but does not adversely affect survival in TAK. Key Points •Renal artery involvement in TAK is associated with chronic renal failure. •TAK with renal artery involvement more often have heart failure and hypertension. •Bilateral renal artery involvement (compared with unilateral) is more often associated with hypertension and visual symptoms. •Renal artery involvement is not associated with an increased risk of mortality in TAK.

Altered immune cell phenotypes within chronically ischemic human kidneys distal to occlusive renal artery disease.

Renal artery stenosis (RAS) is a major cause of ischemic kidney disease, which is largely mediated by inflammation. Mapping the immune cell composition in ischemic kidneys might provide useful insight into the disease pathogenesis and uncover therapeutic targets. We used mass cytometry (CyTOF) to explore the single-cell composition in a unique data set of human kidneys nephrectomized due to chronic occlusive vascular disease (RAS, n = 3), relatively healthy donor kidneys (n = 6), and unaffected sections of kidneys with renal cell carcinoma (RCC, n = 3). Renal fibrosis and certain macrophage populations were also evaluated in renal sections. Cytobank analysis showed in RAS kidneys decreased cell populations expressing epithelial markers (CD45-/CD13+) and increased CD45+ inflammatory cells, whereas scattered tubular-progenitor-like cells (CD45-/CD133+/CD24+) increased compared with kidney donors. Macrophages switched to proinflammatory phenotypes in RAS, and the numbers of IL-10-producing dendritic cells (DC) were also lower. Compared with kidney donors, RAS kidneys had decreased overall DC populations but increased plasmacytoid DC. Furthermore, senescent active T cells (CD45+/CD28+/CD57+), aged neutrophils (CD45+/CD15+/CD24+/CD11c+), and regulatory B cells (CD45+/CD14-/CD24+/CD44+) were increased in RAS. RCC kidneys showed a distribution of cell phenotypes comparable with RAS but less pronounced, accompanied by an increase in CD34+, CD370+, CD103+, and CD11c+/CD103+ cells. Histologically, RAS kidneys showed significantly increased fibrosis and decreased CD163+/CD141+ cells. The single-cell platform CyTOF enables the detection of significant changes in renal cells, especially in subsets of immune cells in ischemic human kidneys. Endogenous pro-repair cell types in RAS warrant future study for potential immune therapy.NEW & NOTEWORTHY The single-cell platform mass cytometry (CyTOF) enables detection of significant changes in one million of renal cells, especially in subsets of immune cells in ischemic human kidneys distal to renal artery stenosis (RAS). We found that pro-repair cell types such as scattered tubular-progenitor-like cells, aged neutrophils, and regulatory B cells show a compensatory increase in RAS. Immune cell phenotype changes may reflect ongoing inflammation and impaired immune defense capability in the kidneys.

Clinical Practice Report of Contrast-Enhanced Ultrasound in Renal Artery Disease.

OBJECTIVES: To evaluate the diagnostic performance of renal artery contrast-enhanced ultrasound (CEUS) with modified inspection section and summarize subsequent changes in imaging assessment of renal artery disease. METHODS: A total of 1015 patients underwent renal artery CEUS were included in the study. Among them, 79 patients (156 renal arteries) suspected with renal artery stenosis (RAS) underwent digital subtraction angiography (DSA) subsequently. DSA was used as the gold standard to evaluate the diagnostic performance of CEUS in detecting RAS (≥30%) and severe stenosis (≥70%), as well as the diagnostic accuracy of classification of stenosis degree. Besides, 127 of the 1015 patients underwent other imaging examinations such as computed tomography angiography (CTA) or magnetic resonance angiography (MRA) after CEUS and annual proportion of these imaging examinations was assessed. RESULTS: The sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of CEUS for detecting RAS (≥30%) was 96.4%, 88.6%, 94.2%, 95.6% and 90.7%, respectively and the kappa value was .857 (P < .01). CEUS had a good performance in distinguishing severe stenosis (≥70%) with a sensitivity of 91.1%, specificity of 95.5%, accuracy of 92.9%, PPV of 96.5%, NPV of 88.7% and the kappa value was 0.857(P < .01). There was no significant difference between CEUS and DSA in detecting stenosis (P = 1.0) and severe stenosis (P = .227). The diagnostic accuracy of CEUS in grading RAS was 85.3% and the kappa value was 0.753 (P < .01). Besides, the annual proportion of other imaging examinations decreased for 4 consecutive years. CONCLUSIONS: CEUS is a non-invasive, safe and valuable technique for the assessment of renal artery disease and worthy of promotion.

Transplant renal artery stenosis: Study of incidence using doppler ultrasound, risk factors and analysis is effect in graft outcomes.

INTRODUCTION AND OBJECTIVES: Transplant renal artery stenosis (TRAS) is a vascular complication after kidney transplantation which estimated incidence is 13%. It could cause refractory arterial hypertension, kidney dysfunction and premature death in transplant recipients. METHODS: We carried out a retrospective study including every patient who underwent renal transplantation between 2014 and 2020. They were evaluated with a systematic post-transplant renal Doppler ultrasound. To identify independent risk factors for transplant renal artery stenosis we performed a multivariate analysis. RESULTS: Seven hundred twenty-four kidney transplants were included, 12% ​​were living donors and 88% were deceased donors. The mean age was 54.8 in recipients and 53 in donors. Transplant renal artery stenosis was diagnosed in 70 (10%) recipients, the majority in the first 6 months after surgery. 51% of patients with transplant renal artery stenosis were managed conservatively. The multivariate analysis showed diabetes mellitus, graft rejection, arterial resuture and donor body mass index as independent risk factors for transplant renal artery stenosis. Survival of the grafts with transplant renal artery stenosis was 98% at 6 months and 95% at two years. CONCLUSIONS: The systematic performance of Doppler ultrasound in the immediate post-transplant period diagnosed 10% of transplant renal artery stenosis in our cohort. Despite the above risk factors, an adequate monitoring and treatment could avoid the increased risk of graft loss in patients with transplant renal artery stenosis.

A rare cause and an even rarer treatment of hypertension in a 5-year-old boy: Mid-aortic syndrome.

Renal artery stenosis is one of the common vascular diseases that cause hypertension in children. However, renal artery aneurysms and abdominal aortic aneurysms, which may be components of mid-aortic syndrome, are rarely associated with renal artery stenosis. Despite its rarity, early diagnosis and treatment are critical to prevent fatal complications. Currently, non-surgical invasive techniques are considered the first choice for treatment, but in some cases, surgery is inevitable. Here, we present a 5-year-old boy with a mid-aortic syndrome. The patient presented with a history of severe headache and epistaxis 5-6 times a day and was diagnosed with hypertension. A 9 × 9 mm saccular aneurysm on the anterior surface of the abdominal aorta at the level of the left renal artery ostium, and a 12 mm aneurysm in the left renal artery after a stenotic segment at the hilum level was detected in the doppler USG and contrast-enhanced imaging techniques. The patient was operated on electively. We used a PTFE patch to repair the abdominal aorta and, saphenous vein which was taken from his father to repair the renal artery. The patient recovered well and was discharged on the 18th day.

Case Report: Renal artery stenosis in children: ultrasound as a decisive diagnostic and therapy-accompanying technique!

Introduction: Renal artery stenosis in children is rare, and the recommended diagnostic algorithm, including techniques such as catheter-based angiography, CT angiography, magnetic resonance angiography, and ultrasound, is controversial in pediatric cohorts. Case presentation: We report a case of an 11-year-old girl with renal artery stenosis in whom ultrasonography played a decisive role in confirming the diagnosis and accompanying therapeutic percutaneous transluminal renal artery angioplasty. Conclusion: Improved ultrasound techniques and the examiner's experience contribute to improving renal artery stenosis diagnosis in children. In particular, localized sensitive blood flow velocity analysis indicates the advantages of ultrasound compared to other imaging modalities in renal artery stenosis. Therefore, ultrasound should be a focus of future study designs addressing the search for the best diagnostic algorithm. Summary: The advantages of ultrasound techniques in pediatric patients with renal artery stenosis compared to other imaging modalities are highlighted.