Wednesday, March 17, 2010

TOPIC DISCUSSION: Renal Artery Stenosis

A recent review in Nature Nephrology, one of my favorite journals talks about the recent trials and overall summary of the diagnosis and treatment of renal artery stenosis.  What I loved about the article is an overall summation of all studies that is noted in table 2. In Box 1, they also list other causes of renal artery stenosis that we often forget to look for:- fibromuscular dysplasia, arterititis( PAN, Takayasu), Tuberous Sclerosis, vascular Ehlers Danlos Syndrome, Renal artery spasm, etc.

Basically, this review article concludes that atherosclerotic renal artery stenosis should be aimed at prolonging the period that is free from cardiovascular or renal events.  Age and age related risk factors, vascular disease, hypertension, renal function and kidney size all are determining factors of how patients should be treated.
Patients with FMD should be treated more aggresively with stenting as angioplasty has a better blood pressure outcome in FMD than atherosclerotic RAS.  but again, each case has to be taken on an individual basis, based on age and other co morbid factors.

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  1. The ASTRAL trial is a recent trial in Nephrology that specifically addresses if unilateral renal artery stenosis should be managed medically or with intervention. The results confirm what many nephrologists suspected - medical management is equally superior to percutaneous intervention.
    All nephrology trainees should know the data of this trial.

  2. Similar results were also shown by STAR trial by Bax et al. Annals of Internal Medicine 2009, 150 (12): 840-48

    The problem with all these trials is patient selection. All these trials have included patients with uncontrolled HTN and renal dysfxn. They have failed to identify patients with significant stenosis > 50% ( even 75%) and Renal resistive index < 80%. These are the subsets of patients who are hypothesized to maximally benefit from intervention.

    To sddress this issue RAVE trial is being conducted, single center randomized, parallel group study comparing renal revascularization with medical therapy alone

    Will establish whether the use of renal resistance index (RRI), can identify patients with renal vascular disease who will not benefit from renal revascularization procedures


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