Original Investigation
Pathogenesis and Treatment of Kidney Disease
High-Risk Clinical Presentations in Atherosclerotic Renovascular Disease: Prognosis and Response to Renal Artery Revascularization

https://doi.org/10.1053/j.ajkd.2013.07.020Get rights and content

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.

Study Design

Single-center prospective cohort study; retrospectively analyzed.

Setting & Participants

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

Predictors

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.

Outcomes

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).

Limitations

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.

Section snippets

Description of Cohort and Inclusion Criteria

Since 1995, information about all patients referred to our tertiary renal center (catchment population, 1.55 million) diagnosed with ARVD (either by intra-arterial digital subtraction angiography or computed tomography/magnetic resonance angiography) has been entered into a prospectively populated database. Each patient record is updated annually by nephrology residents and contains details of imaging results, clinical presentation, comorbid conditions, CV events, prescribed medications, blood

Results

A total of 819 patient records were reviewed, with 109 excluded due to incomplete baseline data, 144 excluded due to renal artery stenosis <50%, and 99 excluded due to unilateral occlusion with stenosis <50% on the contralateral side. Data from 467 patients were analyzed, with a median follow-up of 3.8 (IQR, 1.8-5.8) years. Baseline demographics of excluded patients are presented in Table S2.

One or more high-risk presentation was exhibited by 237 (51%) patients, 58 (24%) of whom underwent

Discussion

To our knowledge, this cohort of 467 patients with an overall revascularization rate of 27%, comparable to that seen in Medicare claims data,3 includes the largest series of patients with flash pulmonary edema, and the only series of patients with flash pulmonary edema to include a medically treated comparator group. These data, representing more than 15 years of clinical practice, reflect the findings of the ASTRAL trial and other randomized trials in a real-life setting: for an unselected

Acknowledgements

Support: None.

Financial Disclosure: The authors declare that they have no relevant financial interests.

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