The appropriateness of renal angioplasty. The ANPARIA software: a multidisciplinary expert panel approach.
Percutaneous transluminal renal angioplasty (PTRA) is an invasive technique that is costly and involves the risk of complications and renal failure. The ability of PTRA to reduce the administration of antihypertensive drugs has been demonstrated. A potentially greater benefit, which nevertheless remains to be proven, is the deferral of the need for chronic dialysis. The aim of the study (ANPARIA) was to assess the appropriateness of PTRA to impact on the evolution of renal function. A standardized expert panel method was used to assess the appropriateness of medical treatment alone or medical treatment with revascularization in various clinical situations. The choice of revascularization by either PTRA or surgery was examined for each clinical situation. Analysis was based on a detailed literature review and on systematically elicited expert opinion, which were obtained during a two-round modified Delphi process. The study provides detailed responses on the appropriateness of PTRA for 1848 distinct clinical scenarios. Depending on the major clinical presentation, appropriateness of revascularization varied from 32% to 75% for individual scenarios (overal 48%). Uncertainty as to revascularization was 41% overall. When revascularization was appropriate, PTRA was favored over surgery in 94% of the scenarios, except in certain cases of aortic atheroma where sugery was the preferred choice. Kidney size [7 cm, absence of coexisting disease, acute renal failure, a high degree of stenosis (C70%), and absence of multiple arteries were identified as predictive variables of favorable appropriateness ratings. Situations such as cardiac failure with pulmonary edema or acute thrombosis of the renal artery were defined as indications for PTRA. This study identified clinical situations in which PTRA or surgery are appropriate for renal artery disease. We built a decision tree which can be used via Internet: the ANPARIA software (http://www.chu-clermontferrand.fr/anparia/). In numerous clinical situations uncertainty remains as to whether PTRA prevents deterioration of renal function.
Gerbaud
Laurent
L
CHU de Clermont-Ferrand, Hôtel-Dieu, Service d'épidémiologie, économie de santé et prévention, 58 rue Montalembert, 63003 Clermont-Ferrand Cedex 01, France.
Manhes
Géraud
G
Debourse
Juliette
J
Gouby
Gérald
G
Glanddier
Phyllis-Yvonne
PY
Vader
John-Paul
JP
Boyer
Louis
L
Deteix
Patrice
P
D017130:Angioplasty / Q000379:methods*; D016009:Chi-Square Distribution; D003663:Decision Trees; D003697:Delphi Technique; D006801:Humans; D020407:Internet; D007511:Ischemia / Q000517:prevention & control; D007668:Kidney / Q000098:blood supply*; D016015:Logistic Models; D010043:Outcome and Process Assessment, Health Care; D011788:Quality of Life; D012078:Renal Artery Obstruction / Q000517:prevention & control*; D051437:Renal Insufficiency / Q000209:etiology / Q000517:prevention & control; D012307:Risk Factors; D012984:Software; D015607:Stents; D016896:Treatment Outcome; D014654:Vascular Patency