RESUMO
BACKGROUND: Transplant Renal Artery Stenosis (TRAS) is a recognized vascular complication after kidney transplantation. The overall risk predictors of TRAS are poorly understood. METHODS: Retrospective analysis of patients with suspected TRAS (Doppler ultrasound PSV > 200 cm/s) who underwent angiographic study in a single center between 2007 and 2014. All patients with stenosis > 50% were considered with TRAS. Stenosis restricted in the body of the artery was also analyzed in a subgroup. RESULTS: 274 patients were submitted to a renal angiography and 166 confirmed TRAS. TRAS group featured an older population (46.3 ± 11.0 vs. 40.9 ±14.2 years; p = 0.001), more frequent hypertensive nephropathy (30.1% vs. 15.7%; p = 0.01), higher incidence of Delayed Graft Function (DGF) (52.0% vs. 25.6%; p < 0.001) and longer Cold Ischemia Time (CIT) (21.5 ± 10.6 vs. 15.7 ± 12.9h; p < 0.001). In multivariable analyses, DGF (OR = 3.31; 95% CI 1.78â6.30; p < 0.0001) was independent risk factors for TRAS. DM and CIT showed a tendency towards TRAS. The compound discriminatory capacity of the multivariable model (AUC = 0.775; 95% CI 0.718â0.831) is significantly higher than systolic blood pressure and creatinine alone (AUC = 0.62; 95% CI 0.558-0.661). In body artery stenosis subgroup, DGF (OR = 1.86; 95% CI 1.04â3.36; p = 0.03) and Diabetes Mellitus (DM) (OR = 2.44; 95% CI 1.31â4.60; p = 0.005) were independent risk factors for TRAS. CONCLUSION: In our transplant population, DGF increased more than 3-fold the risk of TRAS. In the subgroup analysis, both DGF and DM increases the risk of body artery stenosis. The addition of other factors to hypertension and renal dysfunction may increase diagnostic accuracy. TRAS TRIAL REGISTRED: clinicaltrials.gov (n° NCT04225338).
Assuntos
Transplante de Rim , Obstrução da Artéria Renal , Constrição Patológica , Humanos , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: Transplant renal artery stenosis (TRAS) is the main vascular complication of kidney transplantation. For research and treatment purposes, several authors consider critical renal artery stenosis to be greater than 50%, and percutaneous intervention is indicated in this scenario. However, there are no reports in the current literature on the evolution of patients with less than 50% stenosis. METHOD: This retrospective study included data from all patients who underwent kidney transplantation and were suspected of having TRAS after transplantation with stenosis under 50% independent of age and were referred for angiography at a single centre between January 2007 and December 2014. RESULTS: During this period, 6,829 kidney transplants were performed at Hospital do Rim, 313 of whom had a clinical suspicion of TRAS, and 54 of whom presented no significant stenosis. The average age was 35.93 years old, the predominant sex was male, and most individuals (94.4%) underwent dialysis before transplantation. In most cases in this group, transplants occurred from a deceased donor (66.7%). The time between transplantation and angiography was less than one year in 79.6% of patients, and all presented nonsignificant TRAS. Creatinine levels, systolic blood pressure, diastolic blood pressure and glomerular filtration rate improved over the long term. The outcomes found were death and allograft loss. CONCLUSION: Age, sex and ethnic group of patients were factors that did not interfere with the frequency of renal artery stenosis. The outcomes showed that in the long term, most patients evolve well and have improved quality of life and kidney function, although there are cases of death and kidney loss.
Assuntos
AVC Isquêmico/complicações , Transplante de Rim/efeitos adversos , Obstrução da Artéria Renal/etiologia , Adolescente , Adulto , Idoso , Angiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Prognóstico , Qualidade de Vida , Obstrução da Artéria Renal/diagnóstico por imagem , Estudos Retrospectivos , Adulto JovemRESUMO
OBJECTIVE: Endovascular treatment through either percutaneous transluminal angioplasty (PTA) alone or stenting has been previously used as a treatment for transplant renal artery stenosis (TRAS). This review aimed to investigate the results of endovascular treatment for renal artery stenosis in transplanted kidneys as compared with the outcomes of interventions, medical management, and graft survival in non-TRAS patients. METHODS: A systematic review of PubMed, Google Scholar, Cochrane, and Scopus was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in which studies that reported outcomes of the treatment of TRAS via the endoluminal approach were identified, and their results were meta-analyzed. RESULTS: Fifty-four studies with a total of 1522 patients were included. A significant reduction of serum creatinine level was found, favoring the stenting group, with a mean difference of 0.68 mg/dL (95% confidence interval (CI), 0.17-1.19; Z=2.60, p=0.0009). Comparison of pre- and post-intervention values of any intervention revealed a significant decrease in overall serum creatinine level (0.65 mg/dL; 95% CI, 0.40-0.90; Z=5.09, p=0.00001), overall blood pressure, with a mean difference of 11.12 mmHg (95% CI, 7.29-14.95; Z=5.59, p=0.00001), mean difference in the use of medications (0.77; 95% CI, 0.29-1.24; p=0.002), and peak systolic velocity (190.05; 95% CI, 128.41-251.69; p<0.00001). The comparison of serum creatinine level between endovascular interventions and best medical therapy favored endovascular intervention, with a mean difference of 0.23 mg/dL (95% CI, 0.14-0.32; Z=5.07, p<0.00001). Graft survival was similar between the treated patients and those without TRAS (hazard ratio, 0.98; 95% CI, 0.75-1.28; p=0.091). The overall pooled success rate was 89%, and the overall complication rate was 10.4%, with the most prevalent complication being arterial dissection. CONCLUSION: The endovascular treatment of TRAS improves graft preservation and renal function and hemodynamic parameters. PTA + stenting appears to be a more effective option to PTA alone in the stabilization of renal function, with additional benefits from decreased restenosis rates. Further high-quality studies could expand on these findings.
Assuntos
Transplante de Rim , Obstrução da Artéria Renal , Angioplastia/efeitos adversos , Humanos , Transplante de Rim/efeitos adversos , Obstrução da Artéria Renal/diagnóstico por imagem , Obstrução da Artéria Renal/etiologia , Obstrução da Artéria Renal/terapia , Estudos Retrospectivos , Stents/efeitos adversos , Resultado do TratamentoRESUMO
Abstract Background: Transplant Renal Artery Stenosis (TRAS) is a recognized vascular complication after kidney transplantation. The overall risk predictors of TRAS are poorly understood. Methods: Retrospective analysis of patients with suspected TRAS (Doppler ultrasound PSV > 200 cm/s) who underwent angiographic study in a single center between 2007 and 2014. All patients with stenosis > 50% were considered with TRAS. Stenosis restricted in the body of the artery was also analyzed in a subgroup. Results: 274 patients were submitted to a renal angiography and 166 confirmed TRAS. TRAS group featured an older population (46.3 ± 11.0 vs. 40.9 ±14.2 years; p = 0.001), more frequent hypertensive nephropathy (30.1% vs. 15.7%; p = 0.01), higher incidence of Delayed Graft Function (DGF) (52.0% vs. 25.6%; p < 0.001) and longer Cold Ischemia Time (CIT) (21.5 ± 10.6 vs. 15.7 ± 12.9h; p < 0.001). In multivariable analyses, DGF (OR = 3.31; 95% CI 1.78-6.30; p < 0.0001) was independent risk factors for TRAS. DM and CIT showed a tendency towards TRAS. The compound discriminatory capacity of the multivariable model (AUC = 0.775; 95% CI 0.718-0.831) is significantly higher than systolic blood pressure and creatinine alone (AUC = 0.62; 95% CI 0.558-0.661). In body artery stenosis subgroup, DGF (OR = 1.86; 95% CI 1.04-3.36; p = 0.03) and Diabetes Mellitus (DM) (OR = 2.44; 95% CI 1.31-4.60; p = 0.005) were independent risk factors for TRAS. Conclusion: In our transplant population, DGF increased more than 3-fold the risk of TRAS. In the subgroup analysis, both DGF and DM increases the risk of body artery stenosis. The addition of other factors to hypertension and renal dysfunction may increase diagnostic accuracy.
RESUMO
Renal transplant remains the preferred therapy for end-stage renal disease (ESRD). Given the shortage of suitable donor kidneys, use of an expanded criteria donor (ECD) allows marginal kidneys to be transplanted; albeit at risk of increased graft failure due to lower nephron mass. To reduce the risk of graft failure, double kidney transplant (DKT) is advocated, with favorable outcomes. Transplant renal artery stenosis (TRAS) is one of the most common vascular complications following renal transplant. Unlike single kidney transplants, where TRAS usually presents with fluid overload, uncontrolled hypertension, and worsening kidney functions; it may be clinically silent in DKT patients since they have two functional transplanted kidneys. We hereby report a case of TRAS in a DKT patient who had 2 years of favorable clinical outcomes following successful endovascular stenting. He however recently died of COVID-19 associated pneumonitis.
O transplante renal continua sendo a terapia preferida para doenças renais em fase terminal. Dada a escassez de rins de doadores adequados, o doador com critérios expandidos permite que rins marginais sejam transplantados, embora haja um maior risco de falha do enxerto devido à diminuição da massa nefrótica. Para diminuir o risco de falha do enxerto, recomenda-se o transplante renal duplo (TRD), com resultados favoráveis. A estenose de artéria renal transplantada (EART) é uma das complicações vasculares mais comuns após o transplante renal. Ao contrário dos transplantes de rim simples, nos quais a EART geralmente se manifesta como sobrecarga de fluido, hipertensão descontrolada e piora das funções renais, ela pode ser clinicamente silenciosa em pacientes com TRD, pois eles têm dois rins funcionais transplantados. Relatamos aqui um caso de EART em um paciente com TRD que teve resultados clínicos favoráveis por dois anos após o sucesso do implante de stent endovascular. No entanto, ele morreu recentemente de pneumonite associada à covid-19.
RESUMO
In the present case report, we have described a patient with bilateral renal artery occlusion resulting in the acute onset of refractory hypertension and renal failure requiring hemodialysis. Endovascular stenting of the renal arteries was not feasible owing to extensive aortic and renal orifice calcification. After consultation with nephrology and medical optimization, the patient underwent unilateral hepatorenal bypass, with subsequent improvement in renal function and sustained freedom from dialysis. Although percutaneous revascularization has become the preferred option for surgical management of renal artery occlusion, the findings from the present case have demonstrated that hepatorenal bypass remains a viable alternative for more complex cases.
RESUMO
Resistant hypertension is common in the chronic kidney disease population and conveys increased risk for adverse cardiovascular outcomes and the development of kidney failure. Recently, the American College of Cardiology and American Heart Association published a revised scientific statement on the definition and management of resistant hypertension, which codified the long-debated differences between pseudoresistant hypertension and true resistant hypertension. We review this distinction and its importance to nephrologists, who frequently encounter patients for whom antihypertensive therapy fails due to difficulty adhering to complex multidrug regimens. Second, we discuss the evaluation of patients with resistant hypertension, including appropriate screening and diagnostic testing for causes of secondary hypertension. Third, we examine the management of established resistant hypertension, including medication optimization, recent clinical trials supporting lifestyle modifications, and the evidence behind the routine use of mineralocorticoid receptor antagonists. Special attention is given to the vital role of diuretics in the treatment of patients with chronic kidney disease. We propose an algorithm for the diagnosis and management of these cases. Finally, we briefly discuss the current state of antihypertensive device therapies, including kidney denervation and baroreceptor-directed therapies.
Assuntos
Anti-Hipertensivos/farmacologia , Hipertensão , Insuficiência Renal Crônica , Resistência a Medicamentos , Humanos , Hipertensão/complicações , Hipertensão/terapia , Conduta do Tratamento Medicamentoso , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/fisiopatologiaRESUMO
Various vascular complications following renal transplantation include renal artery and vein thrombosis, renal artery stenosis, pseudoaneurysm, and iliac artery dissection. Transplant renal artery stenosis (TRAS) is the most common, while iliac artery dissection is the rarest of these various vascular complications. We describe an elderly male, who had both external iliac artery dissection and TRAS at 2 months following renal transplantation. He underwent successful percutaneous endovascular intervention of both complications. The post-intervention course was uneventful, with improvement in graft renal functions and left lower limb perfusion.
As diversas complicações vasculares possíveis após um transplante renal incluem trombose da veia e artéria renais, estenose da artéria renal, pseudoaneurisma e dissecção da artéria ilíaca. Entre essas diversas complicações, a estenose da artéria renal transplantada é a mais comum, enquanto a dissecção da artéria ilíaca é a mais rara. Relatamos o caso de um homem idoso que desenvolveu tanto dissecção da artéria ilíaca quanto estenose da artéria renal transplantada 2 meses após transplante renal. As intervenções endovasculares percutâneas foram bem-sucedidas em ambas as complicações. O período pós-intervenção cursou sem complicações, com melhora na função renal do enxerto e na perfusão do membro inferior esquerdo.
RESUMO
Abstract Various vascular complications following renal transplantation include renal artery and vein thrombosis, renal artery stenosis, pseudoaneurysm, and iliac artery dissection. Transplant renal artery stenosis (TRAS) is the most common, while iliac artery dissection is the rarest of these various vascular complications. We describe an elderly male, who had both external iliac artery dissection and TRAS at 2 months following renal transplantation. He underwent successful percutaneous endovascular intervention of both complications. The post-intervention course was uneventful, with improvement in graft renal functions and left lower limb perfusion.
Resumo As diversas complicações vasculares possíveis após um transplante renal incluem trombose da veia e artéria renais, estenose da artéria renal, pseudoaneurisma e dissecção da artéria ilíaca. Entre essas diversas complicações, a estenose da artéria renal transplantada é a mais comum, enquanto a dissecção da artéria ilíaca é a mais rara. Relatamos o caso de um homem idoso que desenvolveu tanto dissecção da artéria ilíaca quanto estenose da artéria renal transplantada 2 meses após transplante renal. As intervenções endovasculares percutâneas foram bem-sucedidas em ambas as complicações. O período pós-intervenção cursou sem complicações, com melhora na função renal do enxerto e na perfusão do membro inferior esquerdo.
Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Artéria Renal/patologia , Transplante de Rim/efeitos adversos , Angioplastia , Artéria Ilíaca/patologia , Stents , Constrição Patológica , Procedimentos EndovascularesRESUMO
Abstract Renal transplant remains the preferred therapy for end-stage renal disease (ESRD). Given the shortage of suitable donor kidneys, use of an expanded criteria donor (ECD) allows marginal kidneys to be transplanted; albeit at risk of increased graft failure due to lower nephron mass. To reduce the risk of graft failure, double kidney transplant (DKT) is advocated, with favorable outcomes. Transplant renal artery stenosis (TRAS) is one of the most common vascular complications following renal transplant. Unlike single kidney transplants, where TRAS usually presents with fluid overload, uncontrolled hypertension, and worsening kidney functions; it may be clinically silent in DKT patients since they have two functional transplanted kidneys. We hereby report a case of TRAS in a DKT patient who had 2 years of favorable clinical outcomes following successful endovascular stenting. He however recently died of COVID-19 associated pneumonitis.
Resumo O transplante renal continua sendo a terapia preferida para doenças renais em fase terminal. Dada a escassez de rins de doadores adequados, o doador com critérios expandidos permite que rins marginais sejam transplantados, embora haja um maior risco de falha do enxerto devido à diminuição da massa nefrótica. Para diminuir o risco de falha do enxerto, recomenda-se o transplante renal duplo (TRD), com resultados favoráveis. A estenose de artéria renal transplantada (EART) é uma das complicações vasculares mais comuns após o transplante renal. Ao contrário dos transplantes de rim simples, nos quais a EART geralmente se manifesta como sobrecarga de fluido, hipertensão descontrolada e piora das funções renais, ela pode ser clinicamente silenciosa em pacientes com TRD, pois eles têm dois rins funcionais transplantados. Relatamos aqui um caso de EART em um paciente com TRD que teve resultados clínicos favoráveis por dois anos após o sucesso do implante de stent endovascular. No entanto, ele morreu recentemente de pneumonite associada à covid-19.
Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Obstrução da Artéria Renal/terapia , Trombose , Transplante de Rim/efeitos adversos , Angioplastia , Stents Farmacológicos , Artéria Renal , Transplante de Rim/métodos , Seleção do Doador/métodos , Procedimentos Endovasculares , TransplantadosRESUMO
BACKGROUND: We present a patient with history of sinus venous thrombosis and hypertension during the last year. Her blood pressure was not controlled despite drugs, diet, and exercise. She denied symptoms. She does not smoke nor drink alcohol. Her body mass index was 20 kg/m2, NYHA Class I/IV. CASE SUMMARY: A 40-year-old Latin-American female patient, concerned because despite taking verapamil 160 mg/day, losartan 100 mg/day, and hydrochlorothiazide 25 mg/day her diastolic blood pressure was over 100 mmHg. Routine serum and urine lab tests and a transthoracic echocardiogram were done and were normal. The treatment was increased over the next consultations but without control of her blood pressure. She developed resistant hypertension, and she was taking four antihypertensive drugs and two diuretics. A first renal artery Doppler was normal. Because of a high clinical suspicion a renal angio-CT was performed showing bilateral fibromuscular dysplasia. The patient underwent a renal artery angioplasty with balloon with excellent results and better control of her blood pressure after the procedure. Over the next month, her doctors were able to decrease her treatment to two drugs at intermediate doses. Currently, she is doing well and asymptomatic. DISCUSSION: Renal artery fibromuscular dysplasia (FMD) could be a challenging disease to be diagnosed. Patients with this condition may suffer from symptomatic and resistant hypertension. Many patients do not have abnormalities on their physical exam or in the routine lab tests. Treatment includes renal artery angioplasty if patient is symptomatic and blood pressure is resistant.
RESUMO
Renal imaging has become a fundamental part of clinical care for patients with kidney disease. Imaging strategies for the kidney have been evolving during the past hundred years and have been even more rapidly changing during the past couple of decades due to the development of modern computed tomographic techniques, magnetic resonance imaging, and more sophisticated ultrasonographic techniques, such as contrast-enhanced ultrasonography. Applying the correct radiologic study for the clinical situation maximizes the diagnostic accuracy of the imaging, and a judicious choice between techniques helps limit radiation dose and potential adverse events. This Core Curriculum outlines the imaging modalities currently in use in radiology departments and is divided into 3 sections: (1) a review of the development of renal imaging and an outline of modalities available to the nephrologist, (2) imaging strategies for select clinical situations, and (3) a discussion of some potential adverse events from imaging, including effects of iodinated contrast on kidney function, risks of gadolinium-based contrast agents in kidney failure, and potential risks of imaging techniques that use ionizing radiation.
Assuntos
Rim/diagnóstico por imagem , Imagem Multimodal/métodos , Obstrução da Artéria Renal/diagnóstico , Idoso , Angiografia por Tomografia Computadorizada/métodos , Humanos , Angiografia por Ressonância Magnética/métodos , Masculino , Reprodutibilidade dos Testes , Ultrassonografia Doppler/métodosRESUMO
Resumen La estenosis de la arteria renal es una afección clínica que puede ser asintomática o causar hipertensión arterial sistémica, así como deterioro de la función renal de uno o ambos riñones. La estenosis puede ser causada por aterosclerosis en 90% de los casos y por displasia fibromuscular en 10%, la estenosis de la arteria renal es la principal causa de hipertensión secundaria reversible o modificable si ésta es diagnosticada y tratada antes de cursar con el daño renal. La displasia fibromuscular es indicación de angioplastia percutánea logrando el control de la presión arterial en, incluso, 63% sin antihipertensivos. El objetivo de este artículo es mostrar la complejidad del proceso diagnóstico y la importancia que tiene la sospecha clínica para la corrección oportuna de este tipo de hipertensión arterial reversible.
Abstract Renal artery stenosis (RAS) is a clinical entity that can be asymptomatic or cause systemic arterial hypertension likewise spoil the renal function of one or both kidneys. The stenosis can be caused by atherosclerosis in 90% of the cases and by fibromuscular dysplasia in 10%; the stenosis of the renal artery is the main cause of reversible or modifiable secondary hypertension if it is diagnosed and treated before the renal damage. Fibromuscular dysplasia is an indication for percutaneous angioplasty achieving blood pressure control in up to 63% without antihypertensive drugs. The objective of this paper is to show the complexity of the diagnostic process and the importance of the clinical suspicion for the well-timed correction of this type of arterial hypertension.
RESUMO
La estenosis de la arteria renal es una causa rara de hipertensión arterial neonatal de origen renovascular. Hay muy pocos casos descritos en la literatura en esta etapa. La mayor parte de los pacientes con esta afectación permanecen asintomáticos, y la hipertensión se detecta en las revisiones pediátricas rutinarias. El diagnóstico puede realizarse mediante la combinación de hallazgos bioquímicos y radiológicos. El manejo inicial del paciente se basa en terapia farmacológica hasta alcanzar un crecimiento adecuado para evaluar la reparación definitiva de la lesión vascular o la nefrectomía en caso de supresión funcional del riñón afecto. Se presenta a una paciente femenina recién nacida a término, con hipertensión arterial e importante falla cardíaca congestiva, originada por una estenosis unilateral de la arteria renal, con supresión funcional y atrofia del riñón afecto, que precisó importante soporte inotrópico y antihipertensivo durante los primeros días de vida, con importante mejoría clínica posterior.
Renal artery stenosis represents a rare cause of neonatal arterial hypertension of renovascular origin, having been described few cases in the literature at this stage of life. Most patients with this disease remain asymptomatic; hypertension can be detected in routine pediatric revisions. Diagnosis can be performed by combining biochemical and radiological findings. The initial management consists of pharmacological therapy in order to achieve adequate growth. Subsequently, it is necessary to assess definitive repair of the vascular lesion or nephrectomy in the case of functional abolition of the affected kidney. We present a term newborn female, with arterial hypertension and an important congestive heart failure, caused by a unilateral renal artery stenosis, with functional abolition and atrophy of the affected kidney, which required an important inotropic and antihypertensive support during her first days of life, with significant clinical improvement subsequently.
Assuntos
Humanos , Feminino , Recém-Nascido , Obstrução da Artéria Renal/diagnóstico , Insuficiência Cardíaca/diagnóstico , Hipertensão/diagnóstico , Obstrução da Artéria Renal/complicações , Insuficiência Cardíaca/etiologia , Hipertensão/etiologiaRESUMO
Renal artery stenosis represents a rare cause of neonatal arterial hypertension of renovascular origin, having been described few cases in the literature at this stage of life. Most patients with this disease remain asymptomatic; hypertension can be detected in routine pediatric revisions. Diagnosis can be performed by combining biochemical and radiological findings. The initial management consists of pharmacological therapy in order to achieve adequate growth. Subsequently, it is necessary to assess definitive repair of the vascular lesion or nephrectomy in the case of functional abolition of the affected kidney. We present a term newborn female, with arterial hypertension and an important congestive heart failure, caused by a unilateral renal artery stenosis, with functional abolition and atrophy of the affected kidney, which required an important inotropic and antihypertensive support during her first days of life, with significant clinical improvement subsequently.
La estenosis de la arteria renal es una causa rara de hipertensión arterial neonatal de origen renovascular. Hay muy pocos casos descritos en la literatura en esta etapa. La mayor parte de los pacientes con esta afectación permanecen asintomáticos, y la hipertensión se detecta en las revisiones pediátricas rutinarias. El diagnóstico puede realizarse mediante la combinación de hallazgos bioquímicos y radiológicos. El manejo inicial del paciente se basa en terapia farmacológica hasta alcanzar un crecimiento adecuado para evaluar la reparación definitiva de la lesión vascular o la nefrectomía en caso de supresión funcional del riñón afecto. Se presenta a una paciente femenina recién nacida a término, con hipertensión arterial e importante falla cardíaca congestiva, originada por una estenosis unilateral de la arteria renal, con supresión funcional y atrofia del riñón afecto, que precisó importante soporte inotrópico y antihipertensivo durante los primeros días de vida, con importante mejoría clínica posterior.
Assuntos
Insuficiência Cardíaca/diagnóstico , Hipertensão/diagnóstico , Obstrução da Artéria Renal/diagnóstico , Feminino , Insuficiência Cardíaca/etiologia , Humanos , Hipertensão/etiologia , Recém-Nascido , Obstrução da Artéria Renal/complicaçõesRESUMO
SUMMARY AIM To describe the incidence, diagnosis, and management of systemic arterial hypertension related to renal artery stenosis in patients with Williams-Beuren syndrome. METHODS Sixty-five patients with Williams-Beuren syndrome were evaluated for hypertension. Enrolled patients underwent Doppler sonography of the renal arteries and Doppler echocardiography. Those with Doppler sonography-detected lesions or with normal Doppler sonography but severe hypertension underwent computed tomography or gadolinium-enhanced magnetic resonance angiography of the aorta and renal vessels. Patients needing vascular therapeutic intervention underwent conventional angiography. RESULTS Systemic arterial hypertension was diagnosed in 21/65 patients with Williams-Beuren syndrome (32%; 13 male) with a mean age of 13.9 years (5mo-20yrs). In 8/21 patients renovascular hypertension was detected. Angioplasty was unsuccessful in five patients with renal artery stenosis, requiring additional treatment. Doppler echocardiography showed cardiac abnormalities in 16/21 (76%) hypertensive patients. CONCLUSION Cardiac abnormalities and hypertension in patients with Williams-Beuren syndrome are common. Thus, thorough evaluation and follow-up are necessary to reduce cardiovascular risks and mortality of these patients
RESUMO OBJETIVO Descrever a incidência, o diagnóstico e o tratamento da hipertensão arterial sistêmica relacionada com estenose da artéria renal em pacientes com síndrome de Williams-Beuren. MÉTODOS Sessenta e cinco pacientes com síndrome de Williams-Beuren foram avaliados quanto à presença de hipertensão. Os pacientes foram submetidos à ultrassonografia com Doppler das artérias renais e ecocardiograma Doppler. Aqueles com suspeita de hipertensão renovascular foram submetidos à tomografia computadorizada ou angiografia por ressonância magnética da aorta e vasos renais ou angiografia convencional. RESULTADOS A hipertensão arterial sistêmica foi diagnosticada em 21/65 pacientes com síndrome de Williams-Beuren (32%, 13 do sexo masculino), com idade média de 13,9 anos (5 meses-20 anos). Em 8/21 pacientes foi detectada a hipertensão renovascular. Angioplastia não teve sucesso em cinco pacientes com estenose da artéria renal, necessitando de tratamento adicional. O ecocardiograma Doppler mostrou anormalidades cardíacas em 16/21 (76%) pacientes hipertensos. CONCLUSÃO As anormalidades cardíacas e hipertensão arterial em pacientes com síndrome de Williams-Beuren são muito frequentes, sendo necessários uma avaliação minuciosa e seguimento para diminuir o risco cardiovascular e a morbimortalidade desses pacientes
Assuntos
Humanos , Masculino , Feminino , Lactente , Pré-Escolar , Criança , Adolescente , Adulto , Adulto Jovem , Obstrução da Artéria Renal/complicações , Síndrome de Williams/complicações , Hipertensão/etiologia , Obstrução da Artéria Renal/epidemiologia , Obstrução da Artéria Renal/diagnóstico por imagem , Brasil/epidemiologia , Ecocardiografia Doppler , Incidência , Estudos Prospectivos , Ultrassonografia Doppler , Angiografia por Ressonância Magnética , Síndrome de Williams/epidemiologia , Síndrome de Williams/diagnóstico por imagem , Hipertensão/epidemiologia , Hipertensão/diagnóstico por imagemRESUMO
OBJECTIVES: To evaluate the safety and efficacy of endovascular intervention with angioplasty and stent placement in patients with transplant renal artery stenosis. METHODS: All patients diagnosed with transplant renal artery stenosis and graft dysfunction or resistant systemic hypertension who underwent endovascular treatment with stenting from February 2011 to April 2016 were included in this study. The primary endpoint was clinical success, and the secondary endpoints were technical success, complication rate and stent patency. RESULTS: Twenty-four patients with transplant renal artery stenosis underwent endovascular treatment, and three of them required reinterventions, resulting in a total of 27 procedures. The clinical success rate was 100%. All graft dysfunction patients showed decreased serum creatinine levels and improved estimated glomerular filtration rates and creatinine levels. Patients with high blood pressure also showed improved control of systemic blood pressure and decreased use of antihypertensive drugs. The technical success rate of the procedure was 97%. Primary patency and assisted primary patency rates at one year were 90.5% and 100%, respectively. The mean follow-up time of patients was 794.04 days after angioplasty. CONCLUSION: Angioplasty with stent placement for the treatment of transplant renal artery stenosis is a safe and effective technique with good results in both the short and long term.
Assuntos
Humanos , Masculino , Feminino , Obstrução da Artéria Renal/cirurgia , Stents , Transplante de Rim/efeitos adversos , Angioplastia/métodos , Obstrução da Artéria Renal/sangue , Estudos Retrospectivos , Resultado do Tratamento , Creatinina/sangue , Sobrevivência de Enxerto , Hipertensão/complicações , Anti-Hipertensivos/uso terapêuticoRESUMO
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
OBJECTIVE: The purpose of this study was to evaluate the association between the presence of clinical symptoms of peripheral artery disease and severe renal artery stenosis in patients referred for renal angiography. METHOD: We included 82 patients with clinical suspicion of renovascular hypertension and performed an imaging investigation (renal Doppler ultrasound and/or renal scintigraphy) for possible renal artery stenosis. All patients underwent renal arteriography and were examined for peripheral artery disease based on the presence of intermittent claudication and ankle-brachial index test results. Severe renal artery stenosis was defined as a lesion causing 70% obstruction. RESULTS: Severe renal artery stenosis was present in 32 of 82 (39%) patients. Patients with severe renal artery stenosis were older (63±12 vs 56±12 years, p=0.006), had more intermittent claudication (55 vs 45%, p=0.027), and had a greater prevalence of an ankle-brachial index <0.9 (44% vs 20%, p=0.021) than patients without severe renal artery stenosis. Multivariate logistic regression analysis showed that the presence of intermittent claudication was independently associated with renal artery stenosis ≥70% (OR: 3.33; 95% CI 1.03-10.82, p=0.04), unlike the ankle-brachial index, which showed no association (OR: 1.44; 95% CI 0.37-5.66, p=0.60). CONCLUSION: Intermittent claudication is independently associated with severe renal artery stenosis (≥70%) in patients clinically suspected of having renovascular hypertension.
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Hipertensão Renovascular/complicações , Claudicação Intermitente/complicações , Obstrução da Artéria Renal/complicações , Artéria Renal/diagnóstico por imagem , Angiografia , Hipertensão Renovascular/diagnóstico por imagem , Claudicação Intermitente/diagnóstico por imagem , Cintilografia , Obstrução da Artéria Renal/diagnóstico por imagem , Índice de Gravidade de Doença , Ultrassonografia DopplerRESUMO
Abstract. The aim of this study is to demonstrate the outcomes and efficacy of percutaneous treatment in patients with refractory or poorly controlled hypertension and renal insufficiency secondary to renal artery stenosis. Retrospective study including 16 patients treated by angioplasty and stent implantation. Blood pressure and renal function were evaluated in the first 24 hours, and at 6 months and 12 months follow-up. The mean systolic blood pressure decreased from 170 mm Hg to 145 mm Hg in the first 24 hrs, and to 138 mm Hg after 12 months of follow-up, with the diastolic pressure decreasing from 95 mm Hg to 77 mm Hg in the first 24 hrs and to 70 mm Hg after 12 months of follow-up. The renal function, according to the creatinine values remained stable.
En este estudio proporcionaremos los resultados y la eficacia de la angioplastia con stent en pacientes con estenosis de la arteria renal que presentaron secundariamente una hipertensión arterial mal controlada o refractaria e insuficiencia renal. Estudio retrospectivo donde se incluyeron a 16 pacientes tratados mediante angioplastia con stent, con seguimiento en las primeras 24 h, 6 meses y 12 meses postangioplastia, para vigilancia de las cifras tensionales y de la función renal, logrando reducir la tensión arterial sistólica de 170 mm Hg a 145 mm Hg en las primeras 24 h y a 138 mm Hg en el control de los 12 meses; la presión arterial diastólica pasó de 95 mm Hg a 77 mm Hg en las primeras 24 h, y 70 mm Hg en el control a los 12 meses. En cuanto a la función renal hubo estabilidad.