Effect of renal revascularization on the development of renal dysfunction
               in atherosclerotic ischemic nephropathy

Hagemann, Rodrigo; Silva, Vanessa dos Santos; Franco, Roberto Jorge da Silva; Barretti, Pasqual; Martin, Luis Cuadrado

doi:10.5935/0101-2800.20140076

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Brazilian Journal of Nephrology

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Review Article • J Bras Nefrol 36 (4) • Oct-Dec 2014 • https://doi.org/10.5935/0101-2800.20140076 copy

Effect of renal revascularization on the development of renal dysfunction in atherosclerotic ischemic nephropathy

Authorship SCIMAGO INSTITUTIONS RANKINGS

Chronic kidney disease (CKD) is characterized by a progressive loss of renal function and its main causes are hypertension and diabetes mellitus. Among the causes of hypertension is atherosclerotic renal disease (ARD). The development of CKD in patients with ARD appears to be due not only to the involvement of the main renal arteries, but also of the renal microcirculation, which may explain the fact that the success of the procedure does not guarantee an improvement in the progression of CKD. To date there is no evidence of benefit of angioplasty compared to medical treatment alone in patients with ARD. The present paper analyzes the most significant studies on renal outcomes in patients with ARD undergoing revascularization or medical treatment alone.

angioplasty; renal insufficiency, chronic; renin-angiotensin system; renovascular, hypertension

	Number of cases	% stenosis		Renal function assessment		Angioplasty with or without stenting		ACEi and statins
EMMA	26 controls	> 75% unilateral		SCr CrCl		Angioplasty, two patients stented		ACEi
EMMA	23 cases	> 75% unilateral		CrCl ≥ 50		Angioplasty, two patients stented		ACEi
SNRASCG	30 controls	> 50% unilateral or bilateral		SCr		Angioplasty		ACEi
SNRASCG	25 cases	> 50% unilateral or bilateral		Cr < 5.6		Angioplasty		ACEi
DRASTIC	50 controls	> 50% unilateral or bilateral		SCr		Angioplasty, two patients stented		ACEi Statins
	50 controls			CrCl
	56 cases			Cr < 2.3
STAR	76 controls	> 50% unilateral or bilateral		SCr		Angioplasty, 46 patients stented		ACEi Statins
	76 controls			CrCl
	64 cases			CrCl < 80
ASTRAL	403 controls	> 50% unilateral or bilateral		Inverse creatinine slope 22% with CrCl < 25		Angioplasty with stenting in 95% of the patients		ACEi (more in the case group) Statins
ASTRAL	403 cases	> 50% unilateral or bilateral		Inverse creatinine slope 22% with CrCl < 25		Angioplasty with stenting in 95% of the patients		ACEi (more in the case group) Statins
CORAL	472 controls	> 80% unilateral or bilateral		CrCl.		Angioplasty with stenting in 95% of the patients		ARBs Statins
	472 controls	Between 60-80% with at least 20 mm Hg systolic pressure gradient
	459 cases
	Exclusion criteria		Primary endpoint		Complications		Conclusion
EMMA	Malignant hypertension stroke, APE, MI within the last six months, DBP > 109 despite treatment		BP at the end of follow-up		Three cases of restenosis, one dissection with segmental infarction		Angioplasty allowed better short-term BP management, but was associated with more complications in patients with unilateral ARAS
SNRASCG	Patients under 40 years; stroke or MI within the last three months		Differences in BP and serum Cr between baseline and six months into follow-up		Eight patients with puncture site bleeding; two referred to RRT		BP was not statistically different after six months.
SNRASCG							No differences seen in serum creatinine levels
DRASTIC	Cancer, hypertension secondary to other diseases, unstable coronary disease, CHF, pregnancy		SBP and DBP three and 12 months after randomization		Two cases of cholesterol embolism; six cases of hematoma requiring blood transfusion		BP levels in the third and tenth months were not significantly different. In the third month, CrCl was higher in the angioplasty group, but on twelfth month the difference disappeared
STAR	Kidney < 8 cm Renal artery diameter < 4 mm. CrCl < 15 DM with proteinuria > 3 g/24h malignant hypertension		Decrease greater than 20% on CrCl		Two procedure-related deaths; 17% had puncture site hematomas; one patient referred to RRT		No differences on primary endpoint. Grups had similar survival
ASTRAL	Need for surgical revascularization;		Renal function alteration by inverse creatinine slope		38 complications in 31 of the 359 patients offer angioplasty (9%); 19 severe events		No differences seen in renal function progression
	non-atheromatous disease;
	previous revascularization for renal artery stenosis
CORAL	Need for surgical revascularization;		Major cardiovascular or renal event; death for cardiovascular or renal causes; stroke; MI; hospitalization for CHF; deteriorating renal disease; need for permanent RRT		Arterial dissection in 11 patients		Angioplasty with stenting did not offer additional benefits versus optimized drug therapy for patients with ARAS, SH, or CKD
	fibromuscular dysplasia;
	Cr > 4.0;
	Kidney < 7 cm;
	stenosis not treatable with one stent

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[1] Correspondence to: Rodrigo Hagemann. School of Medicine of - UNESP. Distrito de Rubião Júnior, s/nº. Botucatu, São Paulo, Brasil. CEP: 18618-970. E-mail: rodhagemann@gmail.com