Use of Renin-Angiotensin Inhibitors in People with Renal Artery Stenosis

Abstract

Background and objectives People with atherosclerotic renal artery stenosis may benefit from renin-angiotensin inhibitors, angiotensin-converting enzyme inhibitors, and angiotensin-receptor blockers, but little is known about the factors associated with their use.Design, setting, participants, & measurements The Cardiovascular Outcomes in Renal Atherosclerotic Lesions study (ClinicalTrials.gov identified: NCT00081731) is a prospective, international, multicenter clinical trial that randomly assigned participants with atherosclerotic renal artery stenosis who received optimal medical therapy to stenting versus no stenting from May 2005 through January 2010. At baseline, medication information was available from 853 of 931 randomly assigned participants. Kidney function was measured by serum creatininebased eGFR at a core laboratory.Results Before randomization, renin-angiotensin inhibitors were used in 419 (49%) of the 853 participants. Reninangiotensin inhibitor use was lower in those with CKD (eGFR,60 ml/min per 1.73 m 2 ) (58% versus 68%; P=0.004) and higher in individuals with diabetes (41% versus 27%; P,0.001). Presence of bilateral renal artery stenosis or congestive heart failure was not associated with renin-angiotensin inhibitor use. Although therapy with renin-angiotensin inhibitors varied by study site, differences in rates of use were not related to the characteristics of the site participants. Participants receiving a renin-angiotensin inhibitor had lower systolic BP (mean6SD, 148623 versus 152623 mmHg; P=0.003) and more often had BP at goal (30% versus 22%; P=0.01).Conclusions Kidney function and diabetes were associated with renin-angiotensin inhibitor use. However, these or other clinical characteristics did not explain variability among study sites. Patients with renal artery stenosis who received renin-angiotensin inhibitor treatment had lower BP and were more likely to be at treatment goal.

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS)

“…Większość leków hipotensyjnych (ACEI, ARB, antagoniści wapnia, beta-adrenolityki i diuretyki) jest skuteczna w leczeniu nadciśnienia tętniczego i może spowalniać progresję choroby nerek [219,220]. Większość pacjentów z istotnym RAS bez problemów toleruje leczenie za pomocą ACEI lub ARB.…”

“…Leki te mogą jednak na tyle obniżać ciśnienie hydrostatyczne w naczyniach włosowatych kłębuszków nerkowych, by spowodować przemijające zmniejszenie filtracji kłębuszkowej i wzrost stężenia kreatyniny w surowicy, co uzasadnia ostrożność i ścisłą obserwację. Leki te można zastosować również w przypadku obustronnego RAS lub zwę-żenia w jedynej czynnej nerce, pod warunkiem że pacjenci są bardzo uważnie monitorowani [219,221]. Optymalne BP u pacjentów z chorobą tętnic nerkowych nie jest znane.…”

Endovascular Versus Medical Therapy for Atherosclerotic Renovascular Disease

“…This is in part due to the increased awareness of ischemic renal disease among clinicians as well as the increasing use of noninvasive diagnostic imaging techniques such as magnetic resonance angiography, computed tomography (CT) angiography, and duplex sonography [1••, 2•]. Over 90 % of RAS cases are caused by atherosclerotic renovascular disease (ARVD).…”

Use of Renin-Angiotensin System Blockade in Patients with Renal Artery Stenosis

“…In this edition of CJASN, Evans et al (27) expound on the rich baseline information collected from the CORAL study participants. This cross-sectional analysis explores current trends in RAS blockade prescriptions in patients with renal artery stenosis across multiple international treatment centers.…”

“…Providers at large treatment centers in the United States were far more cautious about the use of RAS blockade compared with providers in other countries. As Evans et al (27) point out, the cross-sectional nature of the data makes it difficult to draw any robust conclusions about the cause of this heterogeneity in prescribing patterns. Regardless, these findings highlight the ongoing controversy and uncertainty with regard to the safety and appropriateness of RAS blockade in renal artery stenosis.…”