The benefit of renal artery stenting in patients with atheromatous renovascular disease and advanced chronic kidney disease.
BACKGROUND
Around 16% of all patients who present with atheromatous renovascular disease (ARVD) in the United States undergo revascularization. Historically, patients with advanced chronic kidney disease (CKD) have been considered least likely to show improvement in renal functional terms, or survival. We aimed to investigate whether differences in outcomes after revascularization compared to medical management might be observed in ARVD patients if stratified by their CKD classes.


METHODS
Two prospective cohorts, a UK center with a traditionally conservative approach, and a German center who undertook a proactive revascularization approach, were compared. An improvement in renal function was defined as > 20% renal improvement at one year's follow-up. To improve validity and comparability, revascularized patients in the UK center were also used within analyses,


RESULTS
347 (UK conservative group), 89 (UK revascularized group), and 472 (German center) patients were included in the analysis. When subdivided by CKD stage, patient ages between the two centers were comparable. Improvements in renal function were observed in twice as many patients who underwent revascularization as compared to medical treatment, particularly in the latter CKD stages, 15.2 (German revascularization) vs. 0% in CKD 1-2, 12.2 (UK), and 32.8 (German) revascularization vs. 14.1% in CKD3, and 53.1 and 53.8 vs. 28.3 in patients with CKD 4-5. The improvements in eGFR were 10.2 (16) and 8.1 (12.5) ml/min/year in the German and UK revascularized groups, respectively, vs. -0.05 (6.8) ml/min/year in the medical cohort in CKD 4-5. Improvements in blood pressure control were noted at 1 year overall and within each CKD category. Multivariate analysis revealed that revascularization independently reduced the risk of death by 45% in all patients combined (RR 0.55, P = 0.013).


CONCLUSIONS
Although this study has significant methodological limitations, it does shows that percutaneous renal revascularization can improve renal function in advanced CKD (stages 4-5), and that this can provide a survival advantage in prospective analysis.
Kalra
Philip A
PA
Department of Renal Medicine, Salford Royal Hospital, Salford, United Kingdom. Philip.kalra@srft.nhs.uk
Chrysochou
Constantina
C
Green
Darren
D
Cheung
Ching M
CM
Khavandi
Kaivan
K
Sixt
Sebastian
S
Rastan
Aljoscha
A
Zeller
Thomas
T
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D050197:Atherosclerosis / Q000150:complications / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D002317:Cardiovascular Agents / Q000627:therapeutic use*; D002908:Chronic Disease; D019992:Databases as Topic; D005260:Female; D005858:Germany; D005919:Glomerular Filtration Rate; D006801:Humans; D007668:Kidney / Q000098:blood supply* / Q000503:physiopathology; D007674:Kidney Diseases / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011446:Prospective Studies; D020127:Recovery of Function; D012078:Renal Artery Obstruction / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D006113:United Kingdom
D002317:Cardiovascular Agents