RESUMO
A 53-year-old man with stable coronary disease and dyslipidemia was admitted with sudden pain of severe intensity in the left flank. Selective catheterization of the left renal artery, followed by alteplase infusion for 6 hours, resolved the patient's symptoms.
Assuntos
Angiografia por Tomografia Computadorizada/métodos , Ventrículos do Coração/diagnóstico por imagem , Infarto , Rim , Obstrução da Artéria Renal , Terapia Trombolítica/métodos , Ecocardiografia/métodos , Fibrinolíticos/administração & dosagem , Humanos , Infarto/diagnóstico por imagem , Infarto/fisiopatologia , Infarto/terapia , Infusões Intra-Arteriais/métodos , Rim/irrigação sanguínea , Rim/diagnóstico por imagem , Rim/patologia , Masculino , Pessoa de Meia-Idade , Obstrução da Artéria Renal/diagnóstico , Obstrução da Artéria Renal/fisiopatologia , Obstrução da Artéria Renal/terapia , Trombose/diagnóstico por imagem , Trombose/terapia , Ativador de Plasminogênio Tecidual/administração & dosagemRESUMO
OBJECTIVE: To describe and standardize an original protocol for fractional flow reserve (FFR) pre and postangioplasty in an initial series of patients with clinically manifested transplant renal artery stenosis (TRAS). BACKGROUND: There is no data in the literature about the use of FFR in TRAS. METHODS: Patients with TRAS detected in a noninvasive study were referred to diagnostic angiography and stenosis considered visually severe (≥ 60%) were included. After selective cannulation, a PressureWire 0.014" (Certus™-St. Jude Medical) was advanced to the distal portion of the vessel. Resting Pd/Pa ratio (ratio of mean distal to lesion and mean proximal pressures) and translesional systolic pressure gradient were obtained and FFR and hyperemic translesional systolic and mean pressure gradients (HSG and HMG) were registered after papaverine induced maximum hyperemia-pre and poststent implantation. Creatinine levels and office blood pressure measurements were registered at the baseline, 6 and 12 months after intervention. RESULTS: Ten consecutive patients had successful stent implantation and were included. After treatment, significant increase in FFR (0.76 ± 0.09 vs. 0.96 ± 0.04, P < 0.001) and reduction in systolic hyperemic gradients (-41.40 ± 19.18, P < 0.001) and mean (-24.00 ± 11.65, P < 0.001) were observed. A strong negative correlation was observed between FFR and percent stenosis diameter-%SD (r = -0.89, P < 0.001) and HSG (r = -0.9, P < 0.001) as well as a strong positive correlation between FFR and baseline Pd/Pa ratio (r = 0.9, P < 0.001). CONCLUSION: FFR was a well-tolerated, valid and reproducible tool during percutaneous intervention for TRAS. Good correlation was observed between FFR and others hemodynamic parameters of lesion severity.
Assuntos
Cateterismo Periférico/métodos , Hemodinâmica , Transplante de Rim/efeitos adversos , Obstrução da Artéria Renal/diagnóstico , Artéria Renal/fisiopatologia , Circulação Renal , Adulto , Angioplastia com Balão/instrumentação , Angiografia por Tomografia Computadorizada , Feminino , Humanos , Hiperemia/fisiopatologia , Masculino , Pessoa de Meia-Idade , Papaverina/administração & dosagem , Valor Preditivo dos Testes , Artéria Renal/diagnóstico por imagem , Artéria Renal/cirurgia , Obstrução da Artéria Renal/fisiopatologia , Obstrução da Artéria Renal/cirurgia , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Stents , Fatores de Tempo , Resultado do Tratamento , Vasodilatadores/administração & dosagemRESUMO
BACKGROUND: The indications for conservative "best medical treatment" (BMT) versus additional renal artery stenting are a matter of ongoing debate. The RADAR study aimed to evaluate the impact of percutaneous renal artery stenting on the impaired renal function in patients with hemodynamically significant atherosclerotic renal artery stenosis (RAS). METHODS: RADAR is an international, prospective, randomized (1:1) controlled study comparing BMT alone versus BMT plus renal artery stenting in patients with duplex sonographic hemodynamically relevant RAS. Follow-up assessments were at 2, 6, and 12 months and at 3 years. The primary endpoint was change in estimated glomerular filtration rate (eGFR) at 12 months. RESULTS: Due to slow enrollment, RADAR was terminated early after inclusion of 86 of the scheduled 300 patients (28.7%). Change in eGFR between baseline and 12 months was 4.3 ± 15.4 ml/min/1.73 m2 (stent group) and 3.0 ± 14.9 ml/min/1.73 m2 (BMT group), p > 0.999. Clinical event rates were low with a 12-month composite of cardiac death, stroke, myocardial infarction, and hospitalization for congestive heart failure of 2.9% in the stent and 5.3% in the BMT group, p = 0.526, and a 3-year composite of 14.8% and 12.0%, p = 0.982. At 3 years, target vessel (re-)vascularization occurred in one patient (3.0%) in the stent group and in 8 patients (29.4%) in the BMT group. CONCLUSION: In RADAR, outcomes of renal artery stenting were similar to BMT. These results have to be interpreted with the caveat that the study did not reach its statistically based sample size. TRIAL REGISTRATION: Clinicaltrials.gov, NCT00640406. Registered on 17 March 2008.
Assuntos
Angioplastia com Balão/instrumentação , Anti-Hipertensivos/uso terapêutico , Aterosclerose/terapia , Término Precoce de Ensaios Clínicos , Hemodinâmica/efeitos dos fármacos , Hipertensão Renovascular/terapia , Obstrução da Artéria Renal/terapia , Stents , Adulto , Idoso , Idoso de 80 Anos ou mais , Angioplastia com Balão/efeitos adversos , Angioplastia com Balão/mortalidade , Anti-Hipertensivos/efeitos adversos , Aterosclerose/diagnóstico por imagem , Aterosclerose/mortalidade , Aterosclerose/fisiopatologia , Brasil , Europa (Continente) , Feminino , Taxa de Filtração Glomerular/efeitos dos fármacos , Humanos , Hipertensão Renovascular/diagnóstico por imagem , Hipertensão Renovascular/mortalidade , Hipertensão Renovascular/fisiopatologia , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Estudos Prospectivos , Obstrução da Artéria Renal/diagnóstico por imagem , Obstrução da Artéria Renal/mortalidade , Obstrução da Artéria Renal/fisiopatologia , Tamanho da Amostra , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler DuplaRESUMO
BACKGROUND: Transplant renal artery stenosis (TRAS), the most common vascular complication after transplant (Tx), leads to resistant hypertension, impaired renal function, and even loss of the graft. The purpose of the study was to investigate the prevalence and factors associated with TRAS in northeastern Brazil. METHODS: The study was conducted as a retrospective case-control study in a population of Tx recipients in a renal Tx center in northeastern Brazil. Demographic and clinical characteristics of the recipients and donors, data related to the surgery, laboratory data, and number of anti-hypertensive drugs were assessed. Statistical analysis was performed with the use of SPSS 17.0. RESULTS: A total of 494 of 529 recipients were assessed, of which 24 had TRAS. The prevalence of TRAS was 4.8%. Twelve patients (50%) were men with a mean age of 46.7 ± 13.5 years. The mean time of diagnosis was 89.9 days after Tx. The risk factors associated with TRAS were number of anti-hypertensive drugs ≥2 (odds ratio, 17.0; confidence interval, 4.1 to 70.4; P = .001) and grafting with 2 or more arteries (odds ratio, 8.9; confidence interval, 1.4 to 56.6; P = .021). There was a significant reduction in mean systolic blood pressure (147.1 ± 23.7 to 127.8 ± 15.2 mm Hg, P = .001) and diastolic blood pressure (86.6 ± 13.0 to 77.6 ± 9.4 mm Hg, P = .001) after TRAS repair and in serum creatinine (2.8 ± 2.4 to 1.9 ± 1.8 mg/dL, P = .04). CONCLUSIONS: Grafts with 2 or more arteries are associated with TRAS, as well as patients who use a higher number of anti-hypertensive drugs. TRAS repair was associated with improved blood pressure control and renal function.
Assuntos
Oclusão de Enxerto Vascular/etiologia , Transplante de Rim/efeitos adversos , Obstrução da Artéria Renal/etiologia , Adulto , Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea , Brasil/epidemiologia , Estudos de Casos e Controles , Feminino , Oclusão de Enxerto Vascular/epidemiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Rim/irrigação sanguínea , Rim/cirurgia , Transplante de Rim/métodos , Masculino , Pessoa de Meia-Idade , Prevalência , Artéria Renal/fisiopatologia , Obstrução da Artéria Renal/epidemiologia , Obstrução da Artéria Renal/fisiopatologia , Insuficiência Renal/etiologia , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
Renal artery stenosis is the main cause of renovascular hypertension and results in ischemic nephropathy characterized by inflammation, oxidative stress, microvascular loss, and fibrosis with consequent functional failure. Considering the limited number of strategies that effectively control renovascular hypertension and restore renal function, we propose that cell therapy may be a promising option based on the regenerative and immunosuppressive properties of stem cells. This review addresses the effects of mesenchymal stem cells (MSC) in an experimental animal model of renovascular hypertension known as 2 kidney-1 clip (2K-1C). Significant benefits of MSC treatment have been observed on blood pressure and renal structure of the stenotic kidney. The mechanisms involved are discussed.
Assuntos
Hipertensão Renovascular/cirurgia , Rim , Transplante de Células-Tronco Mesenquimais , Obstrução da Artéria Renal/cirurgia , Animais , Doença Crônica , Modelos Animais de Doenças , Humanos , Hipertensão Renovascular/imunologia , Hipertensão Renovascular/metabolismo , Hipertensão Renovascular/patologia , Hipertensão Renovascular/fisiopatologia , Rim/imunologia , Rim/metabolismo , Rim/patologia , Rim/fisiopatologia , Células-Tronco Mesenquimais/imunologia , Células-Tronco Mesenquimais/metabolismo , Comunicação Parácrina , Recuperação de Função Fisiológica , Regeneração , Obstrução da Artéria Renal/imunologia , Obstrução da Artéria Renal/metabolismo , Obstrução da Artéria Renal/patologia , Obstrução da Artéria Renal/fisiopatologia , Transdução de SinaisRESUMO
Increased lifespan in the last few decades has substantially changed the scenario for renal artery stenosis. Indeed, because older populations show a higher prevalence of atherosclerotic disease, the incidence of atheromatous renal artery stenosis has also increased. Intuitively, one could surmise that stenosis removal should void both the hypertension and the kidney damage resulting from the obstructive stenosis. Surprisingly, a number of important clinical trials have failed to show the reversion seen in experimental models. The reasons for these differences may be linked to chronicity and inflammation associated with the atherosclerotic lesion. However, the failure to obtain a favorable response may also be related to abnormalities in the contralateral kidney. Indeed, this apparently normal kidney should work to compensate the hemodynamic effects of the ipsilateral stenosed kidney. Instead, structure and function in the contralateral kidney can be altered in renal artery stenosis to the point that this nonstenotic kidney may sustain both, hypertension and progressive kidney disease. Certainly, comparing the effects of clip removal in the Goldblatt model to angioplasty in clinical settings with atherosclerotic lesions may be totally inappropriate. Nevertheless, there remain certain clinical situations such as bilateral renal arterial disease, congestive heart failure, and progressive renal failure, where angioplasty may be an alternative. These approaches however are yet to be tested.
Assuntos
Arteriosclerose/terapia , Hipertensão/etiologia , Obstrução da Artéria Renal/terapia , Angioplastia/métodos , Animais , Arteriosclerose/complicações , Arteriosclerose/patologia , Progressão da Doença , Humanos , Hipertensão/terapia , Incidência , Nefropatias/etiologia , Nefropatias/terapia , Prevalência , Obstrução da Artéria Renal/complicações , Obstrução da Artéria Renal/fisiopatologiaRESUMO
INTRODUCTION: Renal artery stenosis can lead to renovascular hypertension; however, the detection of stenosis alone does not guarantee the presence of renovascular hypertension. Renovascular hypertension depends on activation of the renin-angiotensin system, which can be detected by functional tests such as captopril renal scintigraphy. A method that allows direct measurement of the baseline and post-captopril glomerular filtration rate using chromium-51 labeled ethylenediamine tetraacetic acid ((51)Cr-EDTA) could add valuable information to the investigation of hypertensive patients with renal artery stenosis. The purposes of this study were to create a protocol to measure the baseline and post-captopril glomerular filtration rate using (51)Cr-EDTA, and to verify whether changes in the glomerular filtration rate permit differentiation between hypertensive patients with and without renal artery stenosis. METHODS: This prospective study included 41 consecutive patients with poorly controlled severe hypertension. All patients had undergone a radiological investigation of renal artery stenosis within the month prior to their inclusion. The patients were divided into two groups: patients with (n=21) and without renal artery stenosis, (n=20). In vitro glomerular filtration rate analysis ((51)Cr-EDTA) and (99m)Tc-DMSA scintigraphy were performed before and after captopril administration in all patients. RESULTS: The mean baseline glomerular filtration rate was 48.6+/-21.8 ml/kg/1.73 m(2) in the group wuth renal artery stenosis, which was significantly lower than the GFR of 65.1+/-28.7 ml/kg/1.73m(2) in the group without renal artery stenosis (p=0.04). Captopril induced a significant reduction of the glomerular filtration rate in the group with renal artery stenosis (to 32.6+/-14.8 ml/ kg/1.73m(2), p=0.001) and an insignificant change in the group without RAS (to 62.2+/-23.6 ml/kg/1.73m(2), p=0.68). Scintigraphy with technetium-99m dimercapto-succinic acid (DMSA) did not show significant differences in differential renal function from baseline to post-captopril images in either group. CONCLUSIONS: Captopril induced a decrease in the GFR that could be quantitatively measured with (51)Cr-EDTA. The reduction is more pronounced in hypertensive patients with RAS.
Assuntos
Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Captopril/uso terapêutico , Quelantes , Ácido Edético , Taxa de Filtração Glomerular/efeitos da radiação , Hipertensão Renovascular/diagnóstico por imagem , Obstrução da Artéria Renal/fisiopatologia , Quelantes/farmacocinética , Ácido Edético/farmacocinética , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Cintilografia , Obstrução da Artéria Renal/metabolismo , Ácido Dimercaptossuccínico Tecnécio Tc 99m/farmacocinéticaRESUMO
FUNDAMENTO: A estenose arterial renal (EAR) é uma causa potencialmente reversível de hipertensão arterial sistêmica (HAS) e nefropatia isquêmica. Apesar da revascularização bem sucedida, nem todos os pacientes (pt) apresentam melhora clínica e alguns podem piorar. OBJETIVO: O presente estudo se destina a avaliar o valor do índice de resistividade renal (IR) como preditor dos efeitos da revascularização renal. MÉTODOS: Entre janeiro de 1998 e fevereiro de 2001, 2.933 pacientes foram submetidos ao duplex ultrassom renal. 106 desses pacientes apresentaram EAR significativa e foram submetidos a angiografia e revascularização renal. A pressão arterial (PA) foi medida antes e depois da intervenção, em intervalos de até 2 anos e as medicações prescritas foram registradas. Antes da revascularização, o IR foi medido em 3 locais do rim, sendo obtida uma média dessas medições. RESULTADOS: Dos 106 pacientes, 81 tiveram IR<80 e 25 RI>80. A EAR foi corrigida somente por angioplastia (PTA) em 25 pts, PTA + stent em 56 pts e cirurgicamente em 25 pts. Dos pacientes que se beneficiaram da revascularização renal; 57 dos 81 pacientes com IR <80 apresentaram melhora em comparação a 5 de 25 com IR > 80. Usando um modelo de regressão logística múltipla, o IR esteve significativamente associado à evolução da PA (p = 0,001), ajustado de acordo com os efeitos da idade, sexo, PAS, PAD, duração da hipertensão, o tipo de revascularização, número de fármacos em uso, nível de creatinina, presença de diabete melito, hipercolesterolemia, volume sistólico, doença arterial periférica e coronariana e tamanho renal (OR 99,6-95 por centoCI para OR 6,1-1.621,2). CONCLUSÃO: A resistividade intrarrenal arterial, medida por duplex ultrassom, desempenha um papel importante na predição dos efeitos pós revascularização renal para EAR.
BACKGROUND: Renal artery stenosis (RAS) is a potentially correctable cause of hypertension and ischemic nephropathy. Despite successful renal revascularization, not all patients (pt) overcome it and some get worse. OBJECTIVE: This study was designed to assess the value of renal resistance index (RI) in predicting the outcome of renal revascularization. METHODS: Between Jan 1998 and Feb 2001, 2,933 pts were referred to renal duplex ultrasound. 106 out of these had significant RAS and underwent angiography and renal revascularization. Arterial blood pressure (BP) was measured before and after the intervention, at intervals of up to 2 years and medications recorded. Prior to revascularization, RI was measured at 3 sites of each kidney and averaged. RESULTS: Out of the 106 patients, 81 had RI<80 and 25 RI>80. RAS was corrected with angioplasty (PTA) alone in 25 pts, PTA + stent in 56 pts and corrected by surgery in 25 pts. Of patients who benefited from renal revascularization; 57 of the 81 patients with RI <80 improved as compared to 5 of 25 with RI>80. Using a multiple logistic regression model, RI was significantly associated with BP outcome (p=0.001), adjusted for the effects of age, sex, SBP, DBP, duration of hypertension, type of revascularization, number of medication in use, creatinine level, presence of diabetes mellitus, hypercholesterolemia, stroke, peripheral and coronary artery disease and kidney size (OR 99.6 - 95 percentCI for OR 6.1 to 1,621.2). CONCLUSION: Intrarenal arterial resistance measured by duplex ultrasound plays an important role in predicting BP outcome after renal revascularization for RAS.