RESUMO
BACKGROUND: To date, renal revascularization has not been shown to be advantageous when compared to optimized medical treatment in patients with atheromatous renovascular disease (ARVD). This study aims to investigate the effect of revascularization in patients with pre-intervention worsening renal function and in those with stable renal function. PATIENTS AND METHODS: In this single-centre observational study, patients who were diagnosed with at least 60% angiographic stenosis unilaterally or bilaterally between January 1996 and October 2008 and who were followed-up until February 2011 were retrospectively analysed. Evolution of renal function was determined from the slope of reciprocal of serum creatinine (RCr-slope) before and after diagnostic angiography or revascularization; this required 5 or more creatinine measurements before and at least another 5 measurements post-procedure. Patients were divided into 2 groups: one comprising patients with negative RCr-slope before the procedure and a second group of patients with prior positive RCr-slope. A stepwise, adjusted logistic regression was used to determine the OR of revascularization on attenuation of RCr-slope. RESULTS: Data for 52 patients were analysed. Median age was 64 (58-72) and median follow-up was 15 (8-34) months. Only patients with a negative RCr-slope (-0.0078 (95% CI -0.0174, -0.0033) dl/mg/month) who underwent revascularization manifested an improved RCr-slope during follow-up (+0.0013 (95% CI -0.0002, 0.0039) dl/mg/month, p < 0.001). This finding remained statistically significant even after the adjustment for proteinuria and bilateral arterial disease. CONCLUSION: Revascularization may be indicated for patients with ARVD and progressively worsening renal function. This patient subgroup should ideally be evaluated in future randomized controlled trials.
Assuntos
Angioplastia , Aterosclerose/fisiopatologia , Aterosclerose/terapia , Nefropatias/fisiopatologia , Nefropatias/terapia , Rim/irrigação sanguínea , Stents , Idoso , Angiografia , Aterosclerose/diagnóstico por imagem , Creatinina/sangue , Feminino , Humanos , Rim/diagnóstico por imagem , Nefropatias/diagnóstico por imagem , Testes de Função Renal , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
INTRODUÇÃO: A nefroangioesclerose hipertensiva é importante causa de doença renal crônica com necessidade de diálise. As características que distinguem um portador de hipertensão arterial que evolui com nefroangioesclerose de outro que mantém função renal estável não são bem estabelecidas, devido à dificuldade em assegurar que os portadores daquela doença não sejam, na verdade, portadores de glomerulopatias ou outras doenças renais confundíveis. Dessa maneira, o objetivo deste trabalho foi identificar características clínicas ou laboratoriais que distingam os pacientes que desenvolveram doença renal crônica a partir da hipertensão, confirmada por biópsia renal, daqueles que, mesmo apresentando hipertensão arterial, não desenvolveram nefroangioesclerose. MÉTODOS: Realizou-se comparação retrospectiva de dados clínicos e laboratoriais de 15 portadores de nefroangioesclerose hipertensiva confirmada por biópsia renal e 15 hipertensos oriundos do ambulatório do Centro de Hipertensão Arterial, cuja ausência de nefroangioesclerose foi definida pela ausência de proteinúria. Os grupos foram pareados quanto à idade e gênero. RESULTADOS: Dentre as variáveis avaliadas, tempo de hipertensão arterial, pressão de pulso, glicemia, ácido úrico, creatinina e frequência de uso de diuréticos e simpatolíticos diferiram estatisticamente entre os dois grupos. Todas essas variáveis apresentaram valores maiores no grupo com nefroangioesclerose hipertensiva. CONCLUSÃO: O presente estudo associa a nefroangioesclerose hipertensiva, confirmada por biópsia, com alterações metabólicas, duração e intensidade da hipertensão e corrobora a ideia de que a prevenção primária da hipertensão arterial, postergando o seu início, o controle pressórico mais estrito, quando a hipertensão já está estabelecida, bem como o controle metabólico têm a potencialidade de prevenir o desenvolvimento de nefroangioesclerose hipertensiva.
INTRODUCTION: Hypertensive nephroangiosclerosis is a major cause of chronic kidney disease requiring dialysis. Clinical characteristics that distinguish a patient with hypertension that evolves to nephroangiosclerosis from another that keeps stable renal function are not well established because of the difficulty in ensuring that the carriers of that disease are not actually suffering from glomerulonephritis or other kidney diseases. Thus, our objective was to identify clinical or laboratory features that distinguish the patients who developed chronic renal failure from hypertension, confirmed by renal biopsy, of those who, even with arterial hypertension, did not develop nephroangiosclerosis. METHODS: We conducted a retrospective comparison of clinical and laboratory data of 15 patients with hypertensive nephroangiosclerosis confirmed by renal biopsy and 15 hypertensive patients from the outpatient clinic of the Hypertension Center, whose lack of nephroangiosclerosis was defined as absence of proteinuria. The groups were matched for age and gender. RESULTS: Among the evaluated variables, duration of hypertension, pulse pressure, blood glucose, uric acid, creatinine and frequency of use of diuretics and sympatholytic differed statistically between the two groups. All these variables were higher in nephroangiosclerosis patients. CONCLUSION: This study links biopsy proven hypertensive nephroangiosclerosis with metabolic features, hypertension intensity and duration, corroborating the idea that primary prevention of hypertension, postponing its initiation, a more intensive hemodynamic control (when hypertension is well established) and metabolic control of these patients have the potential to prevent hypertensive nephroangiosclerosis.
Assuntos
Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Hipertensão/complicações , Nefropatias/diagnóstico , Nefropatias/etiologia , Rim/irrigação sanguínea , Rim/patologia , Biópsia , Nefropatias/patologia , Estudos Retrospectivos , Esclerose/etiologia , Esclerose/patologiaRESUMO
Atherosclerotic renal artery stenosis (RAS) and coronary artery disease (CAD) arise from the same multiple risk factors. The purpose of this study was to assess the frequency of previously undiagnosed CAD in patients with angiographically confirmed RAS, by conducting coronary arteriography in the same setting. Of 57 consecutive patients referred for renal arteriography on clinical grounds during a 14-month period, 28 had no RAS and 6 had RAS, but previously documented CAD. Of the remainder 23 patients, 17 (74%; CI 56%-92%) had both RAS and CAD (7 single vessel, 4 two-vessel, and 7 multivessel disease). The clinical characteristics, such as age, blood pressure (BP) levels, signs of heart failure, were no different between those with and without CAD, although the 4 diabetic patients, the 4 patients with fundoscopic findings of grade III retinopathy, 11 of 14 with peripheral arterial disease, and 7 of 8 patients with prior stroke belonged in the CAD group. None developed complications as a result of the two consecutive procedures. The data suggest that in patients with RAS the frequency of silent CAD is high and cannot be predicted on clinical grounds alone, therefore coronary angiography should be routinely recommended in the same setting.