High-risk clinical presentations in atherosclerotic renovascular disease: prognosis and response to renal artery revascularization.
BACKGROUND
Current trial data may not be directly applicable to patients with the highest risk presentations of atherosclerotic renovascular disease, including flash pulmonary edema, rapidly declining kidney function, and refractory hypertension. We consider the prognostic implications of these presentations and response to percutaneous revascularization.


METHODS
Single-center prospective cohort study; retrospectively analyzed.


METHODS
467 patients with renal artery stenosis ≥50%, managed according to clinical presentation and physician/patient preference.


METHODS
Presentation with flash pulmonary edema (n = 37 [7.8%]), refractory hypertension (n = 116 [24.3%]), or rapidly declining kidney function (n = 46 [9.7%]) compared to low-risk presentation with none of these phenotypes (n = 230 [49%]). Percutaneous revascularization (performed in 32% of flash pulmonary edema, 28% of rapidly declining kidney function, and 28% of refractory hypertension patients) compared to medical management.


RESULTS
Death, cardiovascular (CV) event, end-stage kidney disease.


RESULTS
During a median follow-up of 3.8 (IQR, 1.8-5.8) years, 55% died, 33% had a CV event, and 18% reached end-stage kidney disease. In medically treated patients, flash pulmonary edema was associated with increased risk of death (HR, 2.2; 95% CI, 1.4-3.5; P < 0.001) and CV event (HR, 3.1; 95% CI, 1.7-5.5; P < 0.001), but not end-stage kidney disease, compared to the low-risk phenotype. No increased risk for any end point was observed in patients presenting with rapidly declining kidney function or refractory hypertension. Compared to medical treatment, revascularization was associated with reduced risk for death (HR, 0.4; 95% CI, 0.2-0.9; P = 0.01), but not CV event or end-stage kidney disease, in patients presenting with flash pulmonary edema. Revascularization was not associated significantly with reduced risk for any end point in rapidly declining kidney function or refractory hypertension. When these presentations were present in combination (n = 31), revascularization was associated with reduced risk for death (HR, 0.15; 95% CI, 0.02-0.9; P = 0.04) and CV event (HR, 0.23; 95% CI, 0.1-0.6; P = 0.02).


CONCLUSIONS
Observational study; retrospective analysis; potential treatment bias.


CONCLUSIONS
This analysis supports guidelines citing flash pulmonary edema as an indication for renal artery revascularization in atherosclerotic renovascular disease. Patients presenting with a combination of rapidly declining kidney function and refractory hypertension also may benefit from revascularization and may represent a subgroup worthy of further investigation in more robust trials.
Vascular Research Group, Manchester Academic Health Sciences Centre, University of Manchester, Salford Royal NHS Foundation Trust, Salford, United Kingdom.
James
J
Ritchie
Vascular Research Group, Manchester Academic Health Sciences Centre, University of Manchester, Salford Royal NHS Foundation Trust, Salford, United Kingdom.
Darren
D
Green
Vascular Research Group, Manchester Academic Health Sciences Centre, University of Manchester, Salford Royal NHS Foundation Trust, Salford, United Kingdom.
Constantina
C
Chrysochou
Central Manchester NHS Foundation Trust, Manchester Royal Infirmary, Manchester, United Kingdom.
Nicholas
N
Chalmers
United States Renal Data System, Minneapolis, MN.
Robert N
RN
Foley
Vascular Research Group, Manchester Academic Health Sciences Centre, University of Manchester, Salford Royal NHS Foundation Trust, Salford, United Kingdom. Electronic address: philip.kalra@srft.nhs.uk.
Philip A
PA
Kalra
D000368:Aged; D000369:Aged, 80 and over; D017073:Atherectomy / Q000379:methods; D050197:Atherosclerosis / Q000175:diagnosis* / Q000601:surgery; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D012078:Renal Artery Obstruction / Q000175:diagnosis* / Q000601:surgery*; D012189:Retrospective Studies
Atherosclerotic renovascular disease; flash pulmonary edema; rapid loss of kidney function; renal artery stenosis; renal revascularization; resistant hypertension