RESUMEN
Introduction: The immunomodulatory properties of mesenchymal stromal cells (MSC) have been well-characterized in in-vitro and in-vivo models. We have previously shown that liver MSC (L-MSC) are superior inhibitors of T-cell activation/proliferation, NK cell cytolytic function, and macrophage activation compared to adipose (A-MSC) and bone marrow MSC (BM-MSC) in-vitro. Method: To test these observations in-vivo, we infused these types of MSC into mice with unilateral renal artery stenosis (RAS), an established model of kidney inflammation. Unilateral RAS was induced via laparotomy in 11-week-old, male 129-S1 mice under general anesthesia. Control mice had sham operations. Human L-MSC, AMSC, and BM-MSC (5x105 cells each) or PBS vehicle were injected intra-arterially 2 weeks after surgery. Kidney morphology was studied 2 weeks after infusion using micro-MRI imaging. Renal inflammation, apoptosis, fibrosis, and MSC retention were studied ex-vivo utilizing western blot, immunofluorescence, and immunohistological analyses. Results: The stenotic kidney volume was smaller in all RAS mice, confirming significant injury, and was improved by infusion of all MSC types. All MSC-infused groups had lower levels of plasma renin and proteinuria compared to untreated RAS. Serum creatinine improved in micetreated with BM- and L-MSC. All types of MSC located to and were retained within the stenotic kidneys, but L-MSC retention was significantly higher than A- and BM-MSC. While all groups of MSC-treated mice displayed reduced overall inflammation and macrophage counts, L-MSC showed superior potency in-vivo at localizing to the site of inflammation and inducing M2 (reparative) macrophage polarization to reduce inflammatory changes. Discussion: These in-vivo findings extend our in-vitro studies and suggest that L-MSC possess unique anti-inflammatory properties that may play a role in liver-induced tolerance and lend further support to their use as therapeutic agents for diseases with underlying inflammatory pathophysiology.
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Isquemia , Hígado , Macrófagos , Trasplante de Células Madre Mesenquimatosas , Células Madre Mesenquimatosas , Animales , Ratones , Trasplante de Células Madre Mesenquimatosas/métodos , Masculino , Humanos , Hígado/patología , Hígado/inmunología , Isquemia/terapia , Isquemia/inmunología , Macrófagos/inmunología , Modelos Animales de Enfermedad , Inflamación/inmunología , Inflamación/terapia , Activación de Macrófagos , Obstrucción de la Arteria Renal/terapia , Obstrucción de la Arteria Renal/inmunología , Riñón/patología , Riñón/inmunologíaRESUMEN
MT-1207 (MT) as a new antihypertensive drug is under clinical trial. However, its hypotensive mechanism has not been experimentally explored, and it is unknown whether MT can be used for bilateral renal artery stenosis hypertension. Using two-kidney two-clip (2K2C) to mimic bilateral renal artery stenosis in rats, a stroke-prone renovascular hypertension model, the present study further verified its antihypertensive effect, cardiovascular and renal protection, mortality reduction and lifespan prolongation, as well as demonstrated its two novel pharmacological effects for uric acid-lowering and cognition-improving. Notably, MT did not aggravate renal dysfunction; instead, it had beneficial effects on reducing serum uric acid level and maintaining serum K+ at a relatively stable level in 2K2C rats. In contrast, angiotensin receptor blocker losartan aggravated renal dysfunction in 2K2C rats. Mechanistically, MT hypotensive effect was dependent on its blockade of α1 and 5-HT2 receptors, since MT pretreatment abolished these receptor agonists-induced blood pressure elevations in vivo. Further evidence showed MT bound to and interacted with these receptor subtypes including α1A, α1B, α1D, 5-HT2A, 5-HT2B, and 5-HT2C receptors known for control of blood pressure. In conclusion, MT may be used for treatment of bilateral renal artery stenosis hypertension, different from losartan that is prohibited for treatment of bilateral renal artery stenosis hypertension. Targets validation of MT hypotensive mechanism and beneficial effects of MT on uric acid and cognitive function provide new insights for this novel multitarget drug, deserving clinical trial attention.
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Antihipertensivos , Hipertensión Renovascular , Ratas Sprague-Dawley , Obstrucción de la Arteria Renal , Animales , Masculino , Antihipertensivos/farmacología , Antihipertensivos/uso terapéutico , Ratas , Obstrucción de la Arteria Renal/tratamiento farmacológico , Obstrucción de la Arteria Renal/complicaciones , Hipertensión Renovascular/tratamiento farmacológico , Presión Sanguínea/efectos de los fármacos , Ácido Úrico/sangre , Modelos Animales de Enfermedad , Losartán/farmacología , Riñón/efectos de los fármacos , Riñón/metabolismoRESUMEN
BACKGROUND: The ASTRAL trial (Angioplasty and Stenting for Renal Artery Lesions) recruited 806 patients between 2000 and 2007. Patients with atherosclerotic renal artery stenosis (RAS) and clinician uncertainty about the benefit of revascularization were randomized 1:1 to medical therapy with or without renal artery stenting. The initial results were presented in 2009 at a median 33.6-month follow-up, with no benefit of revascularization on renal or cardiovascular outcomes. Surviving patients remained under follow-up until the end of 2013, and the long-term results are presented in this study. METHODS: Data were analyzed to assess whether there was a later impact of revascularization on renal function, cardiovascular events, and survival, including a composite outcome of renal and cardiovascular outcomes and death (as in the CORAL trial [Cardiovascular Outcomes in Renal Atherosclerotic Lesions]). Prespecified subgroup analyses included different categories of renal function, rapid deterioration in kidney function, and degree of RAS. Post hoc analyses of patients with severe RAS (bilateral 70% or >70% in a solitary kidney), those with or without proteinuria, and a per-protocol analysis were performed. RESULTS: The mean age of the entry population was 70.5 years, the mean estimated glomerular filtration rate was 40 mL/min/1.73 m2, the mean RAS was 76%, and the mean blood pressure was 150/76 mmâ Hg; 83% of the revascularization group underwent attempted stenting. The median follow-up was 56.4 months, with 108 patients lost to follow-up. By the end of follow-up, 50% of the evaluable population had died, 18% had suffered a first renal event, and 40% had suffered a first cardiovascular event. No statistical difference was observed for any outcome in the intention-to-treat and per-protocol analyses. CONCLUSIONS: The long-term follow-up of the ASTRAL trial showed no overall benefit of renal revascularization to renal and cardiovascular outcomes. It has been highlighted that a proportion of the population had lower-risk RAS, and there is likely to be merit in further study in a higher-risk population. REGISTRATION: URL: https://www.isrctn.com; Unique identifier: ISRCTN59586944.
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Aterosclerosis , Tasa de Filtración Glomerular , Riñón , Obstrucción de la Arteria Renal , Stents , Humanos , Obstrucción de la Arteria Renal/fisiopatología , Obstrucción de la Arteria Renal/mortalidad , Obstrucción de la Arteria Renal/terapia , Obstrucción de la Arteria Renal/diagnóstico por imagen , Obstrucción de la Arteria Renal/cirugía , Anciano , Masculino , Femenino , Resultado del Tratamiento , Factores de Tiempo , Persona de Mediana Edad , Riñón/irrigación sanguínea , Riñón/fisiopatología , Aterosclerosis/mortalidad , Aterosclerosis/fisiopatología , Aterosclerosis/cirugía , Aterosclerosis/complicaciones , Factores de Riesgo , Índice de Severidad de la Enfermedad , Arteria Renal/cirugía , Arteria Renal/fisiopatología , Anciano de 80 o más Años , Angioplastia/efectos adversos , Angioplastia/mortalidadRESUMEN
Here, we report a rare case of transplant renal artery stenosis in a patient with autosomal dominant polycystic kidney disease who received a kidney from a deceased donor. The transplant renal artery stenosis was caused by the rotation and compression of the transplanted kidney, a consequence of the preexisting polycystic kidney. To address the transplant renal artery stenosis, the patient underwent additional surgical removal of the native polycystic kidney, which corrected the stenosis and restored the function of the transplanted kidney. This case highlighted the importance of monitoring for various causes of renal artery stenosis following kidney transplant.
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Trasplante de Riñón , Riñón Poliquístico Autosómico Dominante , Obstrucción de la Arteria Renal , Humanos , Trasplante de Riñón/efectos adversos , Riñón Poliquístico Autosómico Dominante/cirugía , Riñón Poliquístico Autosómico Dominante/complicaciones , Riñón Poliquístico Autosómico Dominante/diagnóstico , Resultado del Tratamiento , Obstrucción de la Arteria Renal/etiología , Obstrucción de la Arteria Renal/cirugía , Obstrucción de la Arteria Renal/diagnóstico por imagen , Masculino , Donantes de Tejidos , Persona de Mediana Edad , Adulto , Nefrectomía , Angiografía por Tomografía ComputarizadaRESUMEN
OBJECTIVES: Transplant renal artery stenosis (TRAS) is now recognized as a curable disease with a good prognosis if intervention occurs in the early stage. However, the mid-term outcomes of TRAS when treated by percutaneous transluminal angioplasty with stent placement have yet to be fully elucidated. The purpose of this study was to compare mid-term graft and patient survival of TRAS group with a control group. PATIENTS AND METHODS: Ninety-two patients were diagnosed of TRAS between January 2016 and January 2022 in our center. Fifty-six pairs of recipients with grafts from the same donor were selected as a study group with TRAS and a control group without TRAS, respectively. All donor kidneys were from deceased organ donation rather than living donors. The primary endpoints were graft and patient survival. The secondary outcomes were changes in renal graft function. RESULTS: The mean follow-up time for the TRAS group was 43.6 months, while the mean follow-up time for the control group was 45.3 months. In the TRAS group, the age of patients ranged from 11 to 62 years with 39 males and 17 females. In the control group, the age of patients ranged from 18 to 67 years with 40 males and 16 females. In the TRAS group, there were more patients with diabetic nephropathy as the primary renal disease compared to the control group (5/56 vs 0/56), and the incidence of acute rejection was higher in the TRAS group than in the control group (12/56 vs 3/56). Eight patients in the TRAS group and one patient in the control group experienced graft loss (p = .019). Four patients in the TRAS group and four patients in the control group died with functional renal allograft during the follow-up time (p = .989). The levels of eGFR did not differ significantly between the two groups in the first three years after kidney transplant (p > .05). Patients in the TRAS group had worse graft functionality (eGFR, 44.96 ± 18.9 vs 54.9 ± 19.6 mL/min) in the fourth year when compared with the control group (p = .01). CONCLUSIONS: The graft function deteriorated faster, and graft survival was lower in the TRAS group treated by stent placement when compared with a control group without TRAS over the mid-term.
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Supervivencia de Injerto , Trasplante de Riñón , Obstrucción de la Arteria Renal , Stents , Humanos , Masculino , Femenino , Obstrucción de la Arteria Renal/cirugía , Obstrucción de la Arteria Renal/etiología , Obstrucción de la Arteria Renal/terapia , Obstrucción de la Arteria Renal/mortalidad , Persona de Mediana Edad , Trasplante de Riñón/efectos adversos , Adulto , Estudios Retrospectivos , Anciano , Adulto Joven , Adolescente , Niño , Cadáver , Angioplastia/métodos , Tasa de Filtración GlomerularRESUMEN
Randomized clinical trials failed to show additional benefit of renal artery stenting on top of medical therapy. Instead of writing an obituary on renal artery stenting, we try to explain these disappointing results. A transstenotic pressure gradient is needed to reduce renal perfusion and to activate the renin-angiotensin-aldosterone system. In only a minority of patients included in trials, a transstenotic pressure gradient is measured and reported. Like the coronary circulation, integration of physiological lesion assessment will allow to avoid stenting of non-significant lesions and select those patients that are most likely to benefit from renal artery stenting. Renal artery interventions are associated with peri-procedural complications. Contemporary techniques, including radial artery access, no-touch technique to engage the renal ostium and the use of embolic protection devices, will minimize procedural risk. Combining optimal patient selection and meticulous technique might lead to a netto clinical benefit when renal artery stenting is added to optimal medical therapy.
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Obstrucción de la Arteria Renal , Stents , Humanos , Obstrucción de la Arteria Renal/fisiopatología , Obstrucción de la Arteria Renal/terapia , Obstrucción de la Arteria Renal/diagnóstico por imagen , Obstrucción de la Arteria Renal/etiología , Resultado del Tratamiento , Factores de Riesgo , Arteria Renal/fisiopatología , Arteria Renal/diagnóstico por imagen , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Selección de Paciente , Toma de Decisiones ClínicasRESUMEN
PURPOSE: To describe a single-center experience with robotic-assisted endovascular treatment for transplant renal artery stenosis. MATERIALS AND METHODS: This is a single-center, retrospective, feasibility study of 4 consecutive cases of robotic-assisted endovascular surgery for transplant renal artery stenosis from October 2021 to August 2022. RESULTS: All lesions were identified, and stenting was performed with no complications. Conversion to manual control was not necessary. The mean fluoroscopy time was 25.25 min (range 12-60.9). A control Doppler ultrasound was routinely performed, demonstrating no residual lesions in all cases. There was no reintervention during the follow-up period. The operator learning curve was felt to be acceptable. CONCLUSION: Robotic-assisted endovascular treatment is a feasible technique for transplant renal artery stenosis.
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Procedimientos Endovasculares , Estudios de Factibilidad , Trasplante de Riñón , Obstrucción de la Arteria Renal , Procedimientos Quirúrgicos Robotizados , Humanos , Obstrucción de la Arteria Renal/diagnóstico por imagen , Obstrucción de la Arteria Renal/cirugía , Obstrucción de la Arteria Renal/terapia , Estudios Retrospectivos , Masculino , Femenino , Persona de Mediana Edad , Procedimientos Quirúrgicos Robotizados/métodos , Procedimientos Endovasculares/métodos , Stents , Adulto , Resultado del Tratamiento , Anciano , Arteria Renal/diagnóstico por imagen , Arteria Renal/cirugíaRESUMEN
ABSTRACT: A 60-year-old man with a history of end-stage renal disease received renal transplant and had decreasing renal function 4 months later. Nuclear medicine renal flow and functional study showed severely decreased blood flow and decreased function of the right renal allograft. There was focal increased radiotracer uptake at blood flow phase around the anastomosis of the renal allograft artery and the right external iliac artery. CT angiogram revealed right external iliac artery pseudoaneurysm. Interventional radiology angiography reconfirmed the pseudoaneurysm and revealed stenosis at the proximal transplant renal artery. After stent placement, however, there was worse renal allograft blood flow.
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Aneurisma Falso , Trasplante de Riñón , Arteria Renal , Stents , Humanos , Trasplante de Riñón/efectos adversos , Masculino , Persona de Mediana Edad , Aneurisma Falso/diagnóstico por imagen , Arteria Renal/diagnóstico por imagen , Circulación Renal , Anastomosis Quirúrgica , Constricción Patológica , Obstrucción de la Arteria Renal/diagnóstico por imagen , Obstrucción de la Arteria Renal/fisiopatología , Obstrucción de la Arteria Renal/cirugíaRESUMEN
Accurate selection of sampling positions is critical in renal artery ultrasound examinations, and the potential of utilizing deep learning (DL) for assisting in this selection has not been previously evaluated. This study aimed to evaluate the effectiveness of DL object detection technology applied to color Doppler sonography (CDS) images in assisting sampling position selection. A total of 2004 patients who underwent renal artery ultrasound examinations were included in the study. CDS images from these patients were categorized into four groups based on the scanning position: abdominal aorta (AO), normal renal artery (NRA), renal artery stenosis (RAS), and intrarenal interlobular artery (IRA). Seven object detection models, including three two-stage models (Faster R-CNN, Cascade R-CNN, and Double Head R-CNN) and four one-stage models (RetinaNet, YOLOv3, FoveaBox, and Deformable DETR), were trained to predict the sampling position, and their predictive accuracies were compared. The Double Head R-CNN model exhibited significantly higher average accuracies on both parameter optimization and validation datasets (89.3 ± 0.6% and 88.5 ± 0.3%, respectively) compared to other methods. On clinical validation data, the predictive accuracies of the Double Head R-CNN model for all four types of images were significantly higher than those of the other methods. The DL object detection model shows promise in assisting inexperienced physicians in improving the accuracy of sampling position selection during renal artery ultrasound examinations.
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Aprendizaje Profundo , Obstrucción de la Arteria Renal , Arteria Renal , Ultrasonografía Doppler en Color , Humanos , Arteria Renal/diagnóstico por imagen , Ultrasonografía Doppler en Color/métodos , Femenino , Masculino , Obstrucción de la Arteria Renal/diagnóstico por imagen , Persona de Mediana Edad , Anciano , AdultoRESUMEN
Patients with ischemic cerebrovascular disease (ICVD) frequently develop concomitant peripheral artery disease (PAD) or renal artery stenosis (RAS), and multiterritorial atherosclerotic patients usually have a worse prognosis. We aimed to evaluate the status of peripheral atherosclerosis (AS) and cervicocephalic AS (CAS) in ICVD patients with AS, their correlation, and related risk factors contributing to coexisting cervicocephalic-peripheral AS (CPAS). Based on the severity and extent of AS evaluated by computed tomography angiography and ultrasound, the degree of AS was triple categorized to assess the correlation between CAS and PAD/RAS. CAS and PAD/RAS were defined as the most severe stenosis being ≥ 50% luminal diameter in cervicocephalic or lower limb arteries, and a peak systolic velocity at the turbulent site being ≥ 180 cm/s in the renal artery. Among 403 patients with symptom onset within 30 days, CAS, PAD, and RAS occurrence rates were 68.7%, 25.3%, and 9.9%, respectively. PAD was independently associated with the degree of extracranial and intracranial CAS (p = 0.042, OR = 1.428, 95% CI 1.014-2.012; p = 0.002, OR = 1.680, 95% CI 1.206-2.339), while RAS was independently associated with the degree of extracranial CAS (p = 0.001, OR = 2.880, 95% CI 1.556-5.329). Independent CPAS risk factors included an ischemic stroke history (p = 0.033), increased age (p < 0.01), as well as elevated fibrinogen (p = 0.021) and D-dimer levels (p = 0.019). In conclusion, the occurrence rates of RAS and PAD in ICVD patients with AS is relatively high, and with the severity of RAS or PAD increase, the severity of CAS also increase. Strengthening the evaluation of peripheral AS and controlling elevated fibrinogen might be crucial for preventing and delaying the progression of multiterritorial AS in ICVD patients with AS, thereby improving risk stratification and promoting more effective prevention and treatment strategies.
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Enfermedad Arterial Periférica , Humanos , Femenino , Masculino , Factores de Riesgo , Anciano , Persona de Mediana Edad , Enfermedad Arterial Periférica/etiología , Enfermedad Arterial Periférica/complicaciones , Aterosclerosis/complicaciones , Isquemia Encefálica/etiología , Angiografía por Tomografía Computarizada , Trastornos Cerebrovasculares/etiología , Obstrucción de la Arteria Renal/complicaciones , Obstrucción de la Arteria Renal/etiología , Obstrucción de la Arteria Renal/epidemiologíaRESUMEN
Fibromuscular dysplasia (FMD) is a rare nonatherosclerotic, noninflammatory vascular disease affecting mostly renal and carotid arteries and is the second most frequent cause of renal artery stenosis. The symptomatology is dominated by arterial hypertension due to the frequent involvement of the renal arteries and depends on the location of the lesions. Most of the cases are middle-aged women of Caucasian origin. There are two subtypes based on angiographic aspect: multifocal FMD (80% of the cases) and focal FMD (rarer with a more balanced sex ratio). Angioplasty of the renal arteries is generally disappointing with less than 50% cure of hypertension. It appears necessary to improve our knowledge of the FMD and to optimize the selection of eligible patients for revascularization with transdisciplinary collegial therapeutic decision.
La dysplasie fibromusculaire (DFM) est une maladie rare caractérisée par des sténoses segmentaires non artérioscléreuses, non inflammatoires, des artères de moyens calibres, touchant surtout les artères rénales et les carotides. Elle constitue la seconde cause de sténoses des artères rénales. La symptomatologie dépend de la localisation des lésions et est dominée par l'hypertension artérielle (HTA) en raison de l'atteinte fréquente des artères rénales. Cette pathologie touche majoritairement les femmes caucasiennes d'âge moyen. Il en existe deux sous-types, basés sur l'aspect angiographique : la DFM multifocale (80 % des cas) et la DFM focale (plus rare, sex ratio plus équilibré). Les résultats des prises en charge interventionnelles s'avèrent globalement décevants avec moins de 50 % de guérison de l'HTA. Il est nécessaire d'améliorer nos connaissances sur la physiopathologie de la DFM et d'optimiser la sélection des patients éligibles à une revascularisation par une prise de décision thérapeutique collégiale, en réunion de concertation pluridisciplinaire.
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Displasia Fibromuscular , Arteria Renal , Humanos , Displasia Fibromuscular/complicaciones , Arteria Renal/diagnóstico por imagen , Obstrucción de la Arteria Renal/diagnóstico por imagen , Obstrucción de la Arteria Renal/etiología , Obstrucción de la Arteria Renal/complicacionesAsunto(s)
Displasia Fibromuscular , Trasplante de Riñón , Trasplante Autólogo , Humanos , Displasia Fibromuscular/cirugía , Displasia Fibromuscular/complicaciones , Displasia Fibromuscular/diagnóstico por imagen , Trasplante de Riñón/efectos adversos , Femenino , Resultado del Tratamiento , Obstrucción de la Arteria Renal/cirugía , Obstrucción de la Arteria Renal/etiología , Obstrucción de la Arteria Renal/diagnóstico por imagen , Persona de Mediana EdadRESUMEN
Renal artery stenosis can complicate the management of heart failure with reduced ejection fraction, as it is a conventional contraindication to the use of ACE inhibitors. We report a case in which bilateral renal artery revascularisation allowed the safe reintroduction of enalapril (and subsequently sacubitril valsartan) in a patient with severe left ventricular systolic dysfunction. There is a role for renal artery angioplasty in selected patients to allow optimal medical therapy for patients with heart failure due to impaired systolic function.
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Enalapril , Insuficiencia Cardíaca , Obstrucción de la Arteria Renal , Arteria Renal , Valsartán , Humanos , Obstrucción de la Arteria Renal/cirugía , Obstrucción de la Arteria Renal/complicaciones , Obstrucción de la Arteria Renal/terapia , Arteria Renal/cirugía , Valsartán/uso terapéutico , Enalapril/uso terapéutico , Masculino , Tetrazoles/uso terapéutico , Combinación de Medicamentos , Aminobutiratos/uso terapéutico , Disfunción Ventricular Izquierda , Compuestos de Bifenilo , Anciano , Antagonistas de Receptores de Angiotensina/uso terapéuticoRESUMEN
BACKGROUND AND OBJECTIVES: Atherosclerotic renal artery stenosis may cause hypertension, chronic kidney disease and heart failure, but large randomized control trials to date have shown no major additional benefit of renal revascularization over optimal medical management. However, these trials did not consider outcomes specifically in relation to clinical presentations. Given that atherosclerotic renal artery stenosis is a heterogenous condition, measures of success likely differ according to the clinical presentation. Our retrospective study objectives were to determine the effects of revascularization when applied to specific clinical presentations and after careful multi-disciplinary team review. METHODS: All patients presenting to our centre and its referring hospitals with radiological findings of at least one renal artery stenosis > 50% between January 2015 and January 2020 were reviewed at the renovascular multi-disciplinary team meeting with revascularization considered in accordance with international guidelines, notably for patients with anatomically significant renal artery stenosis, adequately sized kidney and presentations with any of; deteriorating kidney function, heart failure syndrome, or uncontrollable hypertension. Optimal medical management was recommended for all patients which included lipid lowering agents, anti-platelets and anti-hypertensives targeting blood pressure ≤ 130/80 mmHg. The effect of revascularization was assessed according to the clinical presentation; blood pressure and number of agents in those with renovascular hypertension, delta glomerular filtration rate in those with ischaemic nephropathy and heart failure re-admissions in those with heart failure syndromes. RESULTS: During this 5-year period, 127 patients with stenosis ≥ 50% were considered by the multidisciplinary team, with 57 undergoing revascularization (17 primarily for severe hypertension, 25 deteriorating kidney function, 6 heart failure syndrome and 9 for very severe anatomical stenosis). Seventy-nine percent of all revascularized patients had a positive outcome specific to their clinical presentation, with 82% of those with severe hypertension improving blood pressure control, 72% with progressive ischaemic nephropathy having attenuated GFR decline, and no further heart failure admissions in those with heart failure. Seventy-eight percent of patients revascularized for high grade stenosis alone had better blood pressure control with 55% also manifesting renal functional benefits. CONCLUSIONS: Multi-disciplinary team discussion successfully identified a group of patients more likely to benefit from revascularization based on 3 key factors: clinical presentation, severity of the renal artery lesion and the state of the kidney beyond the stenotic lesion. In this way, a large proportion of patients can clinically improve after revascularization if their outcomes are considered according to the nature of their clinical presentation.
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Hipertensión Renovascular , Obstrucción de la Arteria Renal , Humanos , Obstrucción de la Arteria Renal/terapia , Obstrucción de la Arteria Renal/complicaciones , Obstrucción de la Arteria Renal/fisiopatología , Estudios Retrospectivos , Anciano , Femenino , Masculino , Hipertensión Renovascular/terapia , Hipertensión Renovascular/etiología , Hipertensión Renovascular/fisiopatología , Hipertensión Renovascular/diagnóstico , Resultado del Tratamiento , Persona de Mediana Edad , Aterosclerosis/complicaciones , Tasa de Filtración Glomerular , Grupo de Atención al Paciente , Antihipertensivos/uso terapéuticoRESUMEN
PURPOSE: Contrast-enhanced duplex ultrasound (CEUS) might be a useful tool to diagnosing renal artery stenosis (RAS). We amalgamated and reviewed the evidence assessing the diagnostic accuracy of CEUS on detecting RAS compared to angiography. METHODS: This preregistered systematic review included studies that compared the presence of RAS via CEUS with angiography. Sources were searched in November 2022 and included Scopus, EMBASE, MEDLINE, CINAHL, and Academic Search Premier (n = 1717). The Quality Assessment of Diagnostic Studies 2 tool assessed study quality. Results are presented narratively. RESULTS: The studies included (n = 11) had a total of 447 unique participants (193 females) and average age of 56 ± 9 years. Five of eleven studies investigated CEUS using SonoVue contrast agent and reported an average accuracy (91% ± 2%), sensitivity (91% ± 3%), specificity (90% ± 5%), negative predictive value (86% ± 6%), and positive predictive value (94% ± 1%) with all values >80%. The accuracy of CEUS using other types of contrast agent (n = 6), including Levovsit (n = 3/6), Definity (n = 1/6), perfienapent emulsion (n = 1/6), and perfluorocarbon-exposed sonicated dextrose albumin (n = 1/6) was mixed. These studies detected an average accuracy of 91 ± 11% (n = 2/3% > 80%), sensitivity of 98% ± 4%, (n = 3/3% > 80%), and specificity of 86% ± 10% (n = 2/3% > 80%). Included studies had generally low risk of bias and applicability concerns except for unclear flow and timing (n = 7/11) and applicability of patient selection (n = 4/11). CONCLUSION: Despite being limited by the heterogeneity of included studies, our review indicates a high overall diagnostic accuracy for CEUS to detect RAS compared to angiography, with the largest evidence-base for SonoVue contrast. Radiologists and hospital decision makers should consider CEUS as an acceptable alternative to angiography.
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Medios de Contraste , Obstrucción de la Arteria Renal , Ultrasonografía Doppler Dúplex , Humanos , Obstrucción de la Arteria Renal/diagnóstico por imagen , Ultrasonografía Doppler Dúplex/métodos , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Arteria Renal/diagnóstico por imagen , Aumento de la Imagen/métodosRESUMEN
BACKGROUND: 3D printing has been used in different medical contexts, although it is underutilised in paediatrics. We present the first use of 3D printing in the management of three paediatric patients with complex renovascular disease. METHODS: Patient-specific 3D models were produced from conventional 2D imaging and manufactured using 3D polyjet printing technology. All three patients had different underlying pathologies, but all underwent multiple endovascular interventions (renal artery balloon angioplasty) prior to 3D printing and subsequent vascular surgery. The models were verified by an expert radiologist and then presented to the multidisciplinary team to aid with surgical planning. RESULTS: Following evaluation of the 3D-printed models, all patients underwent successful uni/bilateral renal auto-transplants and aortic bypass surgery. The 3D models allowed more detailed preoperative discussions and more focused planning of surgical approach, therefore enhancing safer surgical planning. It influenced clinical decision-making and shortened general anaesthetic time. The families and the patients reported that they had a significantly improved understanding of the patient's condition and had more confidence in understanding proposed surgical intervention, thereby contributing to obtaining good-quality informed consent. CONCLUSION: 3D printing has a great potential to improve both surgical safety and decision-making as well as patient understanding in the field of paediatrics and may be considered in wider surgical areas.
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Impresión Tridimensional , Niño , Humanos , Angioplastia de Balón/métodos , Modelos Anatómicos , Obstrucción de la Arteria Renal/cirugía , Obstrucción de la Arteria Renal/diagnóstico por imagen , Obstrucción de la Arteria Renal/terapia , Procedimientos Quirúrgicos Vasculares/métodos , Procedimientos Quirúrgicos Vasculares/instrumentaciónRESUMEN
The double-kiss mini-crush (DKMC) technique has been successfully deployed in the past for the treatment of complex coronary lesions even for left main lesions. Our case report consists of a proof-of-principle that the DKMC technique can be successfully translated as well to the field of complex renal artery lesions. Insightful thinking out-of-the "coronary" box in concert with skillful off-label application of coronary stenting procedures may open the gate for unprecedented opportunities for the treatment of difficult-to-tackle in-stent restenosis in the renal circulation.
Asunto(s)
Recurrencia , Obstrucción de la Arteria Renal , Stents , Humanos , Obstrucción de la Arteria Renal/diagnóstico por imagen , Obstrucción de la Arteria Renal/terapia , Obstrucción de la Arteria Renal/fisiopatología , Obstrucción de la Arteria Renal/etiología , Resultado del Tratamiento , Masculino , Angioplastia de Balón/instrumentación , Grado de Desobstrucción Vascular , Anciano , Arteria Renal/diagnóstico por imagen , Arteria Renal/fisiopatologíaRESUMEN
Introducción y objetivos La estenosis de la arteria del injerto renal (EAR) es una complicación vascular del trasplante renal cuya incidencia estimada es del 13%, la cual puede causar hipertensión arterial refractaria, disfunción renal y muerte prematura en los receptores. Métodos Se realizó un estudio retrospectivo que incluyó a todos los pacientes sometidos a trasplante renal entre 2014 y 2020. Los pacientes fueron evaluados mediante ecografía doppler renal sistemática tras el trasplante. Para identificar los factores de riesgo independientes de la estenosis de la arteria renal tras el trasplante, realizamos un análisis multivariante. Resultados Se incluyeron 724 trasplantes renales, el 12% eran de donante vivo y el 88% de donante fallecido. La edad media en los receptores era de 54,8 años y en los donantes era de 53. Se diagnosticó estenosis de la arteria del injerto renal en 70 (10%) receptores, la mayoría durante los primeros 6 meses después de la intervención. El 51% de los pacientes con estenosis de la arteria del injerto renal se manejaron de manera conservadora. El análisis multivariante mostró que la diabetes mellitus, el rechazo del injerto, la resutura arterial y el índice de masa corporal del donante eran factores de riesgo independientes de estenosis de la arteria renal después del trasplante. La supervivencia de los injertos con estenosis de la arteria del injerto renal fue del 98% a los 6 meses y del 95% a los 2 años. Conclusiones El uso sistemático de la ecografía doppler en el período inmediatamente posterior al trasplante permitió diagnosticar un 10% de estenosis de la arteria del injerto renal en nuestra cohorte. A pesar de los factores de riesgo mencionados anteriormente, un seguimiento y tratamiento adecuados podrían reducir el riesgo de pérdida del injerto en pacientes con estenosis de la arteria del injerto renal. (AU)
Introduction and objectives Transplant renal artery stenosis (TRAS) is a vascular complication after kidney transplantation which estimated incidence is 13%. It could cause refractory arterial hypertension, kidney dysfunction and premature death in transplant recipients. Methods We carried out a retrospective study including every patient who underwent renal transplantation between 2014 and 2020. They were evaluated with a systematic post-transplant renal Doppler ultrasound. To identify independent risk factors for transplant renal artery stenosis we performed a multivariate analysis. Results Seven hundred twenty-four kidney transplants were included, 12% were living donors and 88% were deceased donors. The mean age was 54.8 in recipients and 53 in donors. Transplant renal artery stenosis was diagnosed in 70 (10%) recipients, the majority in the first 6 months after surgery. The 51% of patients with transplant renal artery stenosis were managed conservatively. The multivariate analysis showed diabetes mellitus, graft rejection, arterial resuture and donor body mass index as independent risk factors for transplant renal artery stenosis. Survival of the grafts with transplant renal artery stenosis was 98% at 6 months and 95% at two years. Conclusions The systematic performance of Doppler ultrasound in the immediate post-transplant period diagnosed 10% of transplant renal artery stenosis in our cohort. Despite the above risk factors, an adequate monitoring and treatment could avoid the increased risk of graft loss in patients with transplant renal artery stenosis. (AU)
Asunto(s)
Humanos , Masculino , Femenino , Obstrucción de la Arteria Renal , Trasplante de Riñón , Supervivencia de Injerto , Ultrasonografía Doppler , Estudios RetrospectivosRESUMEN
ABSTRACT: A 10-year-old hypertensive girl underwent 131 I-MIBG scan to rule out neural crest derived tumor. The whole-body images revealed diffuse intense tracer uptake in the right kidney, which persisted in 96-hour images as well. CT renal angiography revealed 90% to 95% right renal artery stenosis. Thereafter, she underwent baseline and angiotensin receptor blockade renal dynamic imaging, which revealed hemodynamically significant renal artery stenosis. Pattern of diffuse and intense 131 I-MIBG uptake, albeit rare, still warrants further evaluation to rule out renal artery stenosis and investigate its hemodynamic significance for appropriate management.