Randomised comparison of percutaneous angioplasty vs continued medical therapy for hypertensive patients with atheromatous renal artery stenosis

Webster, J.; Marshall, Freda; Abdalla, Marwah; Dominiczak, Anna F.; Edwards, Richard; Isles, Christopher; Loose, H; Main, John; Padfield, P L; Russell, IT; Walker, Brandy S.; Watson, M.; Wilkinson, R

doi:10.1038/sj.jhh.1000599

Cited by 464 publications

(43 citation statements)

References 11 publications

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“…11 However, three randomized trials of renal-artery angioplasty failed to show a benefit with respect to blood pressure. 12-14 Two subsequent randomized trials of stenting did not show a benefit with respect to kidney function. 15,16 To our knowledge, no studies to date have been designed specifically to assess clinical outcomes.…”

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confidence: 99%

Stenting and Medical Therapy for Atherosclerotic Renal-Artery Stenosis

et al. 2014

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BACKGROUND Atherosclerotic renal-artery stenosis is a common problem in the elderly. Despite two randomized trials that did not show a benefit of renal-artery stenting with respect to kidney function, the usefulness of stenting for the prevention of major adverse renal and cardiovascular events is uncertain. METHODS We randomly assigned 947 participants who had atherosclerotic renal-artery stenosis and either systolic hypertension while taking two or more antihypertensive drugs or chronic kidney disease to medical therapy plus renal-artery stenting or medical therapy alone. Participants were followed for the occurrence of adverse cardiovascular and renal events (a composite end point of death from cardiovascular or renal causes, myocar-dial infarction, stroke, hospitalization for congestive heart failure, progressive renal insufficiency, or the need for renal-replacement therapy). RESULTS Over a median follow-up period of 43 months (interquartile range, 31 to 55), the rate of the primary composite end point did not differ significantly between participants who underwent stenting in addition to receiving medical therapy and those who received medical therapy alone (35.1% and 35.8%, respectively; hazard ratio with stenting, 0.94; 95% confidence interval [CI], 0.76 to 1.17; P = 0.58). There were also no significant differences between the treatment groups in the rates of the individual components of the primary end point or in all-cause mortality. During follow-up, there was a consistent modest difference in systolic blood pressure favoring the stent group (−2.3 mm Hg; 95% CI, −4.4 to −0.2; P = 0.03). CONCLUSIONS Renal-artery stenting did not confer a significant benefit with respect to the prevention of clinical events when added to comprehensive, multifactorial medical therapy in people with atherosclerotic renal-artery stenosis and hypertension or chronic kidney disease. (Funded by the National Heart, Lung and Blood Institute and others; ClinicalTrials.gov number, NCT00081731.)

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confidence: 99%

Stenting and Medical Therapy for Atherosclerotic Renal-Artery Stenosis

et al. 2014

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“…35 It showed higher efficacy in lowering blood pressure yet no added advantage in terms of reversing or halting the progression of renal disease. 35 However, with advanced medical therapies, the role of RAAS has diminished, and it is no longer superior to medical management. 36 In addition, there is certainly no role for stenting in incidentally identified renal artery stenosis.…”

Section: Discussionmentioning

confidence: 99%

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

Nejim

Arhuidese

Rizwan

et al. 2017

Journal of Vascular Surgery

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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.

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“…The first three studies used change in blood pressure as the primary outcome [7,8,9] and the more recent trials used renal function [10,11,12] or a composite of renal functional change, cardiovascular events and mortality [12] as the primary outcome. The neutral results of these trials have several potential explanations, but an important one is the fact that patients who were most likely to benefit from renal revascularization, namely, the high-risk patients as typified by our group 1 (progressive decline of renal function) comprised only a minority of the randomized populations.…”

Section: Discussionmentioning

confidence: 99%

“…These studies have shown no overall benefit from revascularization [7,8,9,10,11,12], although a recent meta-analysis has shown a significant reduction in the number of anti-hypertensives at the end of follow-up period in the revascularized cohort [13]. …”

Section: Introductionmentioning

confidence: 99%

Attenuation of Renal Functional Decline Following Angioplasty and Stenting in Atherosclerotic Renovascular Disease

Hagemann

Silva

Carvalho

et al. 2016

Nephron

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Background: To date, renal revascularization has not been shown to be advantageous when compared to optimized medical treatment in patients with atheromatous renovascular disease (ARVD). This study aims to investigate the effect of revascularization in patients with pre-intervention worsening renal function and in those with stable renal function. Patients and Methods: In this single-centre observational study, patients who were diagnosed with at least 60% angiographic stenosis unilaterally or bilaterally between January 1996 and October 2008 and who were followed-up until February 2011 were retrospectively analysed. Evolution of renal function was determined from the slope of reciprocal of serum creatinine (RCr-slope) before and after diagnostic angiography or revascularization; this required 5 or more creatinine measurements before and at least another 5 measurements post-procedure. Patients were divided into 2 groups: one comprising patients with negative RCr-slope before the procedure and a second group of patients with prior positive RCr-slope. A stepwise, adjusted logistic regression was used to determine the OR of revascularization on attenuation of RCr-slope. Results: Data for 52 patients were analysed. Median age was 64 (58-72) and median follow-up was 15 (8-34) months. Only patients with a negative RCr-slope (-0.0078 (95% CI -0.0174, -0.0033) dl/mg/month) who underwent revascularization manifested an improved RCr-slope during follow-up (+0.0013 (95% CI -0.0002, 0.0039) dl/mg/month, p < 0.001). This finding remained statistically significant even after the adjustment for proteinuria and bilateral arterial disease. Conclusion: Revascularization may be indicated for patients with ARVD and progressively worsening renal function. This patient subgroup should ideally be evaluated in future randomized controlled trials.

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Randomised comparison of percutaneous angioplasty vs continued medical therapy for hypertensive patients with atheromatous renal artery stenosis

Cited by 464 publications

References 11 publications

Stenting and Medical Therapy for Atherosclerotic Renal-Artery Stenosis

Stenting and Medical Therapy for Atherosclerotic Renal-Artery Stenosis

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

Attenuation of Renal Functional Decline Following Angioplasty and Stenting in Atherosclerotic Renovascular Disease

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