Purpose: To evaluate information on the prevalence and rate of progression of atherosclerotic renovascular disease and the effect of angiotensin-converting enzyme inhibition on this process, with t...

Atherosclerotic Renovascular Disease and Progressive Renal Failure

Although the treatment of atherosclerotic renal artery stenosis with percutaneous angioplasty, stenting, and surgical revascularization has gained widespread use, few prospective randomized controlled trials (RCTs) exist that compare these techniques with each other or against the standard of medical management alone. To facilitate this process and help answer many important questions about the appropriate application of renal revascularization, well-designed and rigorously conducted trials are needed. These trials must have clearly defined goals and must be sufficiently sized and performed so as to withstand intensive outcomes assessment. Toward this end, the present statement provides guidelines and definitions for the design, conduct, evaluation, and reporting of renal artery revascularization RCTs. In addition, areas of critically needed renal artery revascularization investigation are identified. It is hoped that this information will be valuable to the investigator who wishes to conduct research in this important area.

The use of revascularization techniques for the management of renal artery stenosis in patients with hypertension, renal insufficiency, pulmonary edema, and unstable angina has become increasingly prevalent. Renal artery stent placement, in particular, has gained increasing acceptance on the basis of historical results of renal angioplasty1–3⇓⇓ and the attractiveness of percutaneous compared with surgical revascularization.4 Despite extensive clinical experience over the past 10 years and the publication of multiple articles describing renal revascularization with renal artery stents,5–23⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓ renal angioplasty,24–47⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓ and surgical renal revascularization,48–66⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓ few prospective RCTs have been reported.4,67–71⇓⇓⇓ …

Guidelines for the Reporting of Renal Artery Revascularization in Clinical Trials

Atherosclerotic ischemic renal disease.

Ischemic renal disease (IRD) is defined as a clinically important reduction in glomerular filtration rate or loss of renal parenchyma caused by hemodynamically significant renal artery stenosis. IRD is a common and often overlooked clinical entity that presents itself in the setting of extrarenal arteriosclerotic vascular disease in older individuals with azotemia. Eleven to 14% of end-stage renal disease (ESRD) cases are attributable to chronic IRD. A high percentage of patients entering ESRD programs are hypertensive. Many patients with a presumed diagnosis of hypertensive nephrosclerosis actually have undiagnosed ischemic nephropathy as the etiology of their ESRD. It is important for the clinician to identify IRD, because IRD is a potentially reversible cause of chronic renal failure in a hypertensive patient Atherosclerotic renal artery disease is common among patients with coronary artery disease and aortic and peripheral vascular disease. Atherosclerotic renal artery disease is a progressive disorder, and its progression is associated with loss of renal mass and functioning. A decrease in glomerular filtration rate sufficient to cause an elevation of the serum creatinine concentration requires injury to both kidneys. Consequently, IRD can arise from one of two main clinical situations: bilateral hemodynamically significant renal artery stenosis leading to bilateral renal ischemia; and hemodynamically significant renal artery stenosis in a solitary functioning kidney, or in a kidney that is providing the majority of a patient's glomerular filtration. The primary reason for establishing the diagnosis of IRD is the hope that correction of a renal artery stenosis will lead to improvement of renal function, or a delay in progression to ESRD. There are six major clinical settings in which the clinician could suspect IRD: acute renal failure caused by the treatment of hypertension, especially with angiotensin converting enzyme inhibitors; progressive azotemia in a patient with known renovascular hypertension; acute pulmonary edema superimposed upon poorly controlled hypertension and renal failure; progressive azotemia in an elderly patient with refractory or severe hypertension; progressive azotemia in an elderly patient with evidence of atherosclerotic disease; and unexplained progressive azotemia in an elderly patient Noninvasive testing modalities that have been used recently include the angiotensin converting enzyme inhibitor renal scan, duplex Doppler sonography, magnetic resonance angiography, and the spiral computed tomography. Treatment methods include percutaneous transluminal angioplasty, endovascular stenting, and surgical revascularization. The results of treatment for preservation of renal function have been encouraging, with stabilization or improvement in renal function observed in a significant proportion of cases.

Ischemic renal disease: an emerging cause of chronic renal failure and end-stage renal disease.

In 17 elderly patients, 19 angioplasties (17 nonostial, 2 ostial) were performed to treat acute decreases in renal function caused by high-grade renal artery stenosis in patients considered to be high

Richard M. O’Donovan

Papers

Preservation of renal function by percutaneous renal angioplasty in high-risk elderly patients : short-term outcome