Renal vein renin analysis: Limitations of its use in predicting benefit from percutaneous angioplasty

Martin, Louis G.; Cork, Randy D.; Wells, James O.

doi:10.1007/bf02602982

Cited by 18 publications

(9 citation statements)

References 23 publications

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“…The search for a convenient biomarker that could predict favorable outcomes from renal artery revascularization has been long and has included renal vein renin sampling 26 , captopril renography 27 , peripheral renal vein renin 28 , kidney size 29 , renal resistive index 30 , and serum brain natriuretic peptide levels 31 , but there is no consensus on an ideal biomarker and none were used to select patients for the two largest randomized clinical trials of renal artery stenting, CORAL and ASTRAL 3, 4 . Some believe that patients with the most refractory blood pressure 32, 33 , renal fractional flow reserve 34 , stenosis severity 35 , or trans-stenotic pressure gradients 36 benefit most from renal artery stenting.…”

Section: Discussionmentioning

confidence: 99%

Relationship of Albuminuria and Renal Artery Stent Outcomes

et al. 2016

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Randomized clinical trials have not shown an additional clinical benefit of renal artery stent placement over optimal medical therapy alone. However, studies of renal artery stent placement have not examined the relationship of albuminuria and treatment group outcomes. The CORAL study is a prospective clinical trial of 947 participants with atherosclerotic renal artery stenosis randomized to optimal medical therapy (OMT) with or without renal artery stent which showed no treatment differences (35.8% and 35.1% event rate at mean 43 month follow-up). In a post-hoc analysis, the study population was stratified by the median baseline urine albumin/creatinine ratio (uACR)(n=826) and analyzed for the 5-year incidence of the primary endpoint (myocardial infarction, hospitalization for congestive heart failure, stroke, renal replacement therapy, progressive renal insufficiency, or cardiovascular- or kidney disease-related death), as well as for each component of the primary endpoint, and overall survival. When baseline uACR was <= median (22.5 mg/g, n=413), renal artery stenting was associated with significantly better event-free survival from the primary composite endpoint (73% vs 59% at 5 years, p=.02), cardiovascular disease-related death (93% vs. 85%, p=<.01), progressive renal insufficiency (91% vs 77%, p=.03), and overall survival (89% vs. 76%, p=<.01), but not when baseline uACR was > median (n=413). These data suggest that low albuminuria may indicate a potentially large subgroup of those with renal artery stenosis that could experience improved event-free and overall-survival after renal artery stent placement plus OMT compared with OMT alone. Further research is needed to confirm these preliminary observations.

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Section: Discussionmentioning

confidence: 99%

Relationship of Albuminuria and Renal Artery Stent Outcomes

et al. 2016

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“…Whereas the experimental Goldblatt models are compelling demonstrations of renin-angiotensin activation due to RAS (28), the mechanisms of hypertension in humans with and without RAS are far more complex and include sympathetic and cerebral nervous system activation, vasoactive oxygen species, abnormalities in endothelial dependent relaxation, and ischemic and hypertensive intrarenal injury (29 -31). Patients with ARAS do not have renovascular hypertension, as evidenced by similarities in the extent of renin activation compared with hypertensive patients without RAS and the low cure rate of hypertension after successful revascularization (32,33). The most likely explanations are that patients with ARAS have essential hypertension, many do not have renal ischemia, and unrecognized hypertensive nephropathy leads to self-perpetuating hypertension.…”

Section: Outcomes After Renal Artery Revascularizationmentioning

confidence: 98%

Refining the Approach to Renal Artery Revascularization

Safian

Madder

2009

JACC: Cardiovascular Interventions

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Renal artery stenosis (RAS) is caused by a heterogenous group of diseases with different pathophysiology, clinical manifestations, treatment approaches, and outcomes. The 2 most common forms of RAS are fibromuscular dysplasia (FMD) and atherosclerosis (ARAS). Renovascular syndromes are broadly classified into renovascular hypertension and ischemic nephropathy, but these terms are misleading, because they imply a causal relationship between RAS, hypertension, and renal dysfunction, which is difficult to prove in humans. Data supporting renal revascularization are limited by heterogeneous causes of hypertension and renal dysfunction, insufficient understanding of the relationship between RAS and nephropathy, inconsistent techniques for revascularization, ambiguous terminology and end points to assess benefit, and lack of large-scale randomized trials. The purpose of this review is to enhance understanding of the epidemiology, clinical markers, and diagnosis of RAS; the relationship between RAS and important disease states; the distinction between renal ischemia and nephropathy; optimal revascularization techniques; and avoidance of renal injury.

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“…Although experimental Goldblatt models elegantly demonstrate reninangiotensin activation due to RAS, 12 patients with atherosclerotic RAS often have indistinguishable levels of renin activation compared to hypertensive patients without RAS, 13,14 suggesting that most patients with hypertension and RAS do not have renovascular hypertension (defined as hypertension caused by RAS and cured by renal revascularization). Instead, hypertension may be due to other etiologies, including essential hypertension associated with sympathetic and cerebral nervous system activation, vasoactive oxygen species, abnormalities in endothelial-dependent relaxation, or ischemic and hypertensive intrarenal injury.…”

Section: Article See P 537mentioning

confidence: 99%

Atherosclerotic Renal Artery Stenosis, the Oculostenotic Reflex, and Therapeutic Nihilism

Madder

Safian

2010

Circ: Cardiovascular Interventions

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F ifteen years ago, Topol and Nissen 1 described the oculostenotic reflex as an "irresistible temptation … to perform angioplasty on any significant residual stenosis," highlighting a widely held misperception that an angiographically severe stenosis must cause ischemia and that revascularization results in clinical benefit. Although quantitative angiography improves the accuracy of stenosis severity, it does not improve the accuracy of diagnosing ischemia. In fact, more than one third of angiographically severe coronary stenoses are hemodynamically insignificant by fractional flow reserve (FFR), and FFR results are highly correlated with findings of ischemia by myocardial perfusion imaging. 2 Similarly, angiographic renal artery stenosis (RAS) severity correlates poorly with hemodynamic significance. 3 Article see p 537Five randomized trials 4 -8 demonstrated that a strategy of renal revascularization based on the oculostenotic reflex was not associated with improvement in blood pressure or renal function or reduction in clinical events compared to medical therapy alone. These results lead some to recommend a nihilistic approach to all patients with RAS and to even withhold reimbursement for renal stent procedures. 9 Potential explanations for the negative results of revascularization include treatment of patients with anatomic stenosis but no renal ischemia, baseline parenchymal renal disease precluding improvement in hypertension and renal function, and essential hypertension without renovascular components. 10 In this issue of Circulation: Cardiovascular Interventions, Mangiacapra et al 11 suggest that invasive assessment of renal ischemia by measurement of translesional pressure gradient after administration of intraarterial dopamine might predict the blood pressure response after renal artery stenting. These investigators are authorities on the physiological assessment of arterial stenoses, and a dopamine-induced mean pressure gradient Ն20 mm Hg before revascularization was the only independent predictor of improvement in blood pressure. However, only 53 patients with RAS were evaluated, and the receiver operating characteristic area under the curve was 0.77, consistent with only modest accuracy in predicting a decrease in systolic blood pressure Ն20 mm Hg at 3 months. Although the number of medications was reduced from 3.2 to 2.8 after stenting, this observation alone probably is insufficient to justify renal revascularization. It is interesting that 18% of nonresponders had a dopamine-induced mean pressure gradient Ͼ20 mm Hg, suggesting considerable heterogeneity in blood pressure response.There are several explanations for the variable blood pressure response, even if renal ischemia is present. Although experimental Goldblatt models elegantly demonstrate reninangiotensin activation due to RAS, 12 patients with atherosclerotic RAS often have indistinguishable levels of renin activation compared to hypertensive patients without RAS, 13,14 suggesting that most patients with hypertension and RAS do not have...

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Renal vein renin analysis: Limitations of its use in predicting benefit from percutaneous angioplasty

Cited by 18 publications

References 23 publications

Relationship of Albuminuria and Renal Artery Stent Outcomes

Relationship of Albuminuria and Renal Artery Stent Outcomes

Refining the Approach to Renal Artery Revascularization

Atherosclerotic Renal Artery Stenosis, the Oculostenotic Reflex, and Therapeutic Nihilism

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