Renal artery stenosis: diagnostic strategy and treatment

If essential hypertension is a disease of theories, then renovascular hypertension is a disease of experiments. No other form of experimental hypertension has been more widely studied. The pathophysiology of renovascular hypertension is known in great detail. The question, however, of how to translate the experimental knowledge into clinical practice is a different matter, and the answer is far from clear. The main difficulty is that renovascular hypertension in experimental animals is not the same as hypertension associated with renal artery stenosis in humans. Renal artery stenosis in humans is in most cases caused by atherosclerosis, a progressive disease quite different from the silver clip in experimental animals. In the kidney, atherosclerosis does not only affect the large arteries but also the small arteries and arterioles. Furthermore, atherosclerosis is not limited to the kidney, it also affects the heart and the brain. There is no cure for atherosclerosis; restenosis after angioplasty is still a daunting problem. Finally, renal artery stenosis can be a complication of essential hypertension or essential hypertension can coincide with renovascular hypertension. Renal artery stenosis may cause severe and refractory hypertension and it frequently does so. This will lead to multiple organ damage such as hypertensive retinopathy, left ventricular hypertrophy, coronary vascular disease, heart failure and cerebrovascular accident? Progression of renal artery stenosis to renal artery occlusion results in loss of kidney function, and, in case of bilateral renal artery involvement or in the presence of atherosclerotic disease of smaller renal arteries, it will lead to end-stage renal failure

Stent placement for renal arterial stenosis: where do we stand? A meta-analysis

PURPOSE: To perform a meta-analysis of renal arterial stent placement in comparison with renal percutaneous transluminal angioplasty (PTA) in patients with renal arterial stenosis. MATERIALS AND METHODS: Studies dealing with renal arterial stent placement (14 articles; 678 patients) and renal PTA (10 articles; 644 patients) published up to August 1998 were selected. A random-effects model was used to pool the data. RESULTS: Renal arterial stent placement proved highly successful, with an initial adequate performance in 98% and major complications in 11%. The overall cure rate for hypertension was 20%, whereas hypertension was improved in 49%. Renal function improved in 30% and stabilized in 38% of patients. The restenosis rate at follow-up of 6-29 months was 17%. Stent placement had a higher technical success rate and a lower restenosis rate than did renal PTA (98% vs 77% and 17% vs 26%, respectively; P <.001). The complication rate was not different between the two treatments. The cure rate for hypertension was higher and the improvement rate for renal function was lower after stent placement than after renal PTA (20% vs 10% and 30% vs 38%, respectively; P <.001). CONCLUSION: Renal arterial stent placement is technically superior and clinically comparable to renal PTA alone

Coronary artery calcification as a marker for coronary artery stenosis: comparing kidney failure to the general population

Rationale & Objective: The presence of calcified plaques in the coronary arteries is associated with cardiovascular mortality and is a hallmark of chronic kidney failure, but it is unclear whether this is associated with the same degree of coronary artery stenosis as in patients without kidney disease. We compared the relationship of coronary artery calcification (CAC) and stenosis between dialysis patients and patients without chronic kidney disease (CKD).Study Design: Observational cohort study.Setting & Participants: 127 dialysis patients and 447 patients without CKD with cardiovascular risk factors underwent cardiac computed tomography (CT), consisting of non-contrast-enhanced CT and CT angiography. CAC score and degree of coronary artery stenosis were assessed by independent readers.Predictor: Dialysis treatment.Outcome: Association between calcification and stenosis.Analytical Approach: Logistic regression to determine the association between CAC score and the presence of stenosis in a matched cohort and, in the full cohort, testing for the interaction of dialysis status with this relationship.Results: 112 patients were matched from each cohort, totaling 224 patients, using propensity scores for dialysis, balancing numerous cardiovascular risk factors. Median CAC score was 210 (IQR, 19-859) in dialysis patients and 58 (IQR, 0254) in patients without CKD; 35% of dialysis patients and 36% of patients without CKD had coronary artery stenosis >= 50%. Per each 100-unit higher CAC score, the matched dialysis cohort had significantly lower ORs for stenosis than the nonCKD cohort, 0.67 (95% CI, 0.52-0.83) for stenosis >= 50% and 0.75 (95% CI, 0.62-0.90) for stenosis >= 70%.Limitations: No comparison with the gold standard fractional flow reserve.Conclusions: Dialysis patients have higher risk for coronary artery stenosis with higher CAC scores, but this risk is comparatively lower than in patients without CKD with similar CAC scores. In dialysis patients, a high CAC score can easily be found without significant stenosis. Our data enable "translation" of degree of calcification to the probability of coronary stenosis in dialysis patients.Cardiovascular Aspects of Radiolog

DIALysis or not: Outcomes in older kidney patients with GerIatriC Assessment (DIALOGICA): rationale and design (vol 22, 39, 2021)

An amendment to this paper has been published and can be accessed via the original article.Nephrolog

DIALysis or not: outcomes in older kidney patients with GerIatriC Assessment (DIALOGICA): rationale and design

Background The incidence and prevalence of older patients with kidney failure who are dependent on dialysis is increasing. However, observational studies showed limited or no benefit of dialysis on mortality in subgroups of these patients when compared to conservative care. As the focus is shifting towards health-related quality of life (HRQoL), current evidence of effects of conservative care or dialysis on HRQoL in older patients is both limited and biased. Dialysis comes with both high treatment burden for patients and high costs for society; better identification of patients who might not benefit from dialysis could result in significant cost savings. The aim of this prospective study is to compare HRQoL, clinical outcomes, and costs between conservative care and dialysis in older patients.MethodsThe DIALysis or not: Outcomes in older kidney patients with GerIatriC Assessment (DIALOGICA) study is a prospective, observational cohort study that started in February 2020. It aims to include 1500 patients from 25 Dutch and Belgian centres. Patients aged >= 70years with an eGFR of 10-15mL/min/1.73m(2) are enrolled in the first stage of the study. When dialysis is initiated or eGFR drops to 10mL/min/1.73m(2) or lower, the second stage of the study commences. In both stages nephrogeriatric assessments will be performed annually, consisting of questionnaires and tests to assess most common geriatric domains, i.e. functional, psychological, somatic, and social status. The primary outcome is HRQoL, measured with the Twelve-item Short-Form Health Survey. Secondary outcomes are clinical outcomes (mortality, hospitalisation, functional status, cognitive functioning, frailty), cost-effectiveness, and decisional regret. All outcomes are (repeated) measures during the first year of the second stage. The total follow-up will be a maximum of 4 years with a minimum of 1 year in the second stage.DiscussionBy generating more insight in the effects of conservative care and dialysis on HRQoL, clinical outcomes, and costs, findings of this study will help patients and physicians make a shared decision on the best individual treatment option for kidney failure.Trial registrationThe study was registered in the Netherlands Trial Register (NL-8352) on 5 February 2020.Clinical epidemiolog

Recovery of dialysis patients with COVID-19 : health outcomes 3 months after diagnosis in ERACODA

Background. Coronavirus disease 2019 (COVID-19)-related short-term mortality is high in dialysis patients, but longer-term outcomes are largely unknown. We therefore assessed patient recovery in a large cohort of dialysis patients 3 months after their COVID-19 diagnosis. Methods. We analyzed data on dialysis patients diagnosed with COVID-19 from 1 February 2020 to 31 March 2021 from the European Renal Association COVID-19 Database (ERACODA). The outcomes studied were patient survival, residence and functional and mental health status (estimated by their treating physician) 3 months after COVID-19 diagnosis. Complete follow-up data were available for 854 surviving patients. Patient characteristics associated with recovery were analyzed using logistic regression. Results. In 2449 hemodialysis patients (mean ± SD age 67.5 ± 14.4 years, 62% male), survival probabilities at 3 months after COVID-19 diagnosis were 90% for nonhospitalized patients (n = 1087), 73% for patients admitted to the hospital but not to an intensive care unit (ICU) (n = 1165) and 40% for those admitted to an ICU (n = 197). Patient survival hardly decreased between 28 days and 3 months after COVID-19 diagnosis. At 3 months, 87% functioned at their pre-existent functional and 94% at their pre-existent mental level. Only few of the surviving patients were still admitted to the hospital (0.8-6.3%) or a nursing home (∼5%). A higher age and frailty score at presentation and ICU admission were associated with worse functional outcome. Conclusions. Mortality between 28 days and 3 months after COVID-19 diagnosis was low and the majority of patients who survived COVID-19 recovered to their pre-existent functional and mental health level at 3 months after diagnosis

Endothelin and active renin levels in essential hypertension and hypertension with renal artery stenosis before and after percutaneous transluminal renal angioplasty

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The place of renal scintigraphy in the diagnosis of renal artery stenosis: fifteen years of clinical experience

Contains fulltext : 25063___.PDF (publisher's version ) (Open Access

Quantifying exposure to calcium and phosphate in ESRD; predictive of atherosclerosis on top of arteriosclerosis?

Background: Long-term exposure to hypercalcaemia and hyperphosphataemia leads to media calcification and predicts mortality in patients with end-stage renal disease (ESRD). It is debatable whether this exposure is only a risk factor for arteriosclerosis, or also for superimposed atherosclerosis. Calcium-phosphate exposure is difficult to quantify, because it is variable in time and exerts its deleterious effects only after prolonged presence. Methods: In 90 dialysis patients, calcium and phosphate values from the complete dialysis period were collected. From three-month averages, measures for calcium-phosphate exposure were derived after exclusion of transplant periods. Calcium-phosphate exposure was then related to intima-media thickness (IMT) and to ankle-brachial index (ABI) as markers of early atherosclerosis. Results: Calcium-phosphate exposure was quantified in three ways using 1670 patient-quarters (i.e. three-months periods) covering 93% of the time on dialysis: averaged calcium-phosphate exposure, percentage of time with above-reference values, and burden of hypercalcaemia/hyperphosphataemia represented by this percentage multiplied by months on dialysis. No association was found with IMT. Patients with increased, not decreased, ABI had higher calcium-phosphate exposure throughout dialysis treatment: hyperphosphataemia burden was 31 (19 to 43) months for patients with ABI between 0.90 and 1.40 and 79 (58 to 100) months for patients with ABI >1.40 or incompressible ankle arteries (