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      A Study on the Outcome of Percutaneous Transluminal Renal Angioplasty in Patients with Renal Failure

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          Background: The indications for percutaneous transluminal renal angioplasty (PTRA) in renovascular disease, as well as its benefits, remain a matter of debate. The aim of this study was to evaluate the outcome of angioplasty and to identify risk factors associated with less successful outcomes in patients with atheromatous renal artery stenosis and renal failure of varying degrees. Methods: The results of PTRA were analyzed retrospectively in 144 patients with serum creatinine levels of >130 µmol/l. Patients were divided into 5 groups according to their indication for angioplasty: (1) deteriorating renal function; (2) accelerating hypertension; (3) a combination of 1 and 2; (4) peripheral vascular disease, and (5) miscellaneous conditions. Results: The baseline mean (± SD) systolic and diastolic blood pressures of the entire group were lowered from 180 ± 32 and 95 ± 16 mm Hg to 162 ± 23 and 86 ± 12 mm Hg, respectively (p < 0.0005), 12 months after angioplasty. The blood pressure level was unaffected by angioplasty in patients with claudication. The mean number of antihypertensive drugs was reduced in the group with accelerating hypertension from 2.9 ± 0.8 to 2.4 ± 1.2 (p = 0.019), and in the group with unilateral renal artery stenosis and two kidneys from 2.4 ± 1.0 to 1.8 ± 1.1 (p = 0.002), 12 months after PTRA. Glomerular filtration rate at 3-month follow-up had increased from 23 ± 11 to 27 ± 14 ml/min/1.73 m<sup>2</sup> (p = 0.021) in group 1, from 25 ± 11 to 28 ± 14 ml/min/1.73 m<sup>2</sup> (p = 0.031) in the combined group of patients consisting of groups 1 and 3, and from 32 ± 13 to 35 ± 14 ml/min/1.73 m<sup>2</sup> (p = 0.019) in the group with unilateral renal artery stenosis. No statistically significant difference was found in any of these 3 groups 1 year after angioplasty. The first patient group had an increased prevalence of cardiovascular disease, aortic aneurysm, carotid occlusive disease, and peripheral vascular disease compared to the other patient groups (p < 0.05). Patients with baseline creatinine levels of >300 µmol/l had a lower survival rate at 12, 60, and 120 months after PTRA than patients with serum creatinine levels of <300 µmol/l (p < 0.005). Survival was also lower in patients with bilateral renal artery stenosis and those with a single kidney, compared to patients with a unilateral stenosis at both 5 and 10 years after PTRA (p < 0.05). Regression analysis of predictor variables of mortality rate showed that the relative risk (RR) associated with increased serum creatinine was 4.7 (CI 2.0–11.0; p < 0.0005). The RR for older patients was 1.1 (CI 1.0–1.2; p = 0.008), and the RR for former smokers was 6.0 (CI 1.6–24.0; p = 0.009). Conclusion: The results of the present study indicate that glomerular filtration can be improved in patients who primarily undergo angioplasty to rescue renal function. Renal function with creatinine levels of >300 µmol/l was associated with a lower survival rate. It is, therefore, possible that patients selected after a thorough evaluation of their renal function and comorbid disease factors may benefit from PTRA, even when the indication for angioplasty is to salvage renal function.

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          Most cited references 5

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          Contrast-induced nephropathy: definition, epidemiology, and patients at risk.

          Radiological procedures utilizing intravascular iodinated contrast media injections are being widely applied for both diagnostic and therapeutic purposes. This has resulted in an increasing incidence of procedure-related contrast-induced nephropathy (CIN). The definition of CIN includes absolute (> or = 0.5 mg/dl) or relative increase (> or = 25%) in serum creatinine at 48-72 h after exposure to a contrast agent compared to baseline serum creatinine values, when alternative explanations for renal impairment have been excluded. Although the risk of renal function impairment associated with radiological procedures is low (0.6-2.3%) in the general population, it may be very high in selected patient subsets (up to 20%), especially in patients with underlying cardiovascular disease. This review provides information on the known risk factors for the development of CIN, and completes with describing user-friendly CIN risk score based on the readily available information.
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            The effect of balloon angioplasty on hypertension in atherosclerotic renal-artery stenosis. Dutch Renal Artery Stenosis Intervention Cooperative Study Group.

            Patients with hypertension and renal-artery stenosis are often treated with percutaneous transluminal renal angioplasty. However, the long-term effects of this procedure on blood pressure are not well understood. We randomly assigned 106 patients with hypertension who had atherosclerotic renal-artery stenosis (defined as a decrease in luminal diameter of 50 percent or more) and a serum creatinine concentration of 2.3 mg per deciliter (200 micromol per liter) or less to undergo percutaneous transluminal renal angioplasty or to receive drug therapy. To be included, patients also had to have a diastolic blood pressure of 95 mm Hg or higher despite treatment with two antihypertensive drugs or an increase of at least 0.2 mg per deciliter (20 micromol per liter) in the serum creatinine concentration during treatment with an angiotensin-converting-enzyme inhibitor. Blood pressure, doses of antihypertensive drugs, and renal function were assessed at 3 and 12 months, and patency of the renal artery was assessed at 12 months. At base line, the mean (+/-SD) systolic and diastolic blood pressures were 179+/-25 and 104+/-10 mm Hg, respectively, in the angioplasty group and 180+/-23 and 103+/-8 mm Hg, respectively, in the drug-therapy group. At three months, the blood pressures were similar in the two groups (169+/-28 and 99+/-12 mm Hg, respectively, in the 56 patients in the angioplasty group and 176+/-31 and 101+/-14 mm Hg, respectively, in the 50 patients in the drug-therapy group; P=0.25 for the comparison of systolic pressure and P=0.36 for the comparison of diastolic pressure between the two groups); at the time, patients in the angioplasty group were taking 2.1+/-1.3 defined daily doses of medication and those in the drug-therapy group were taking 3.2+/-1.5 daily doses (P<0.001). In the drug-therapy group, 22 patients underwent balloon angioplasty after three months because of persistent hypertension despite treatment with three or more drugs or because of a deterioration in renal function. According to intention-to-treat analysis, at 12 months, there were no significant differences between the angioplasty and drug-therapy groups in systolic and diastolic blood pressures, daily drug doses, or renal function. In the treatment of patients with hypertension and renal-artery stenosis, angioplasty has little advantage over antihypertensive-drug therapy.
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              Continuing uncertainty about the value of percutaneous revascularization in atherosclerotic renovascular disease: a meta-analysis of randomized trials.

              To study the effect of revascularization on blood pressure (BP) and serum creatinine (SCr) in patients with atherosclerotic renovascular disease (ARVD). Three randomized studies comparing balloon angioplasty (plus medication if necessary) with medical therapy alone in patients with ARVD were identified. In one study, patients were stratified and analysed according to whether they had unilateral or bilateral disease. Therefore, four sets of results were available for inclusion in a meta-analysis comparing BP and SCr at 6 months and changes from baseline. The three trials recruited 210 patients. There was no clear benefit for angioplasty when comparing BP at 6 months. Relative to the medical therapy group, the mean (95% CI) systolic/diastolic BP was 2.9 mmHg (-9.1, 3.4)/0.35 mmHg (-3.6, 2.9) lower in the angioplasty group (P=0.4/0.8). There was, however, some suggestion of benefit for angioplasty when changes in BP were compared. There was a greater reduction in the systolic/diastolic BP in the angioplasty group, with a difference of 6.3 mmHg (-11.7, -0.8)/3.3 mmHg (-6.2, -0.4) in the mean change (P=0.02/0.03). There was some suggestion of benefit for angioplasty in terms of changes in SCr, although this was not significant (P=0.06). The reported trials have been too small to determine reliably the role of angioplasty in ARVD. Although the combined results of three previous trials exclude the possibility of a large improvement in renal function or hypertension after angioplasty, a moderate but clinically worthwhile benefit cannot be ruled out. Further large-scale randomized evidence is needed.

                Author and article information

                Nephron Clin Pract
                Nephron Clinical Practice
                S. Karger AG
                October 2006
                09 August 2006
                : 104
                : 3
                : c132-c142
                Department of Nephrology and Transplantation, Malmö University Hospital, Malmö, Sweden
                94916 Nephron Clin Pract 2006;104:c132–c142
                © 2006 S. Karger AG, Basel

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