Effect of renal-artery stenting on progression of renovascular renal failure

Abstract

In response to Harden and colleagues' report,1Harden PN MacLeod MJ Rodger RSC et al.Effect of renal-artery stenting on progression of renovascular renal failure.Lancet. 1997; 349: 1133-1136Summary Full Text Full Text PDF PubMed Scopus (406) Google Scholar we describe our experience of renal-artery stenting. 12 patients (eight men) with a median age of 73 (range 56–78) years were treated consecutively with renal-stent placement from April, 1992, and followed up for at least 6 months. Five patients had a bilateral renal-artery stenosis and five had renal-artery stenosis in either surgical or functional solitary kidneys. 17 kidneys were revascularised with Palmaz stents (Johnson and Johnson Interventional Systems, Warren, NJ, USA). Technical success was achieved in all patients. One patient required surgical repair for a pseudoaneurysm at the femoral artery puncture site. Patients were followed every 6 months with duplex sonography, and in two cases with angiography after 12 months and 38 months, respectively. There was no evidence of a significant restenosis in any patient. Follow-up ranged from 2 months to 87 months before stenting (median 7 months), and from 7 months to 56 months thereafter (median 30.5 months). We assessed renal outcomes by comparison of prestenting serum concentrations of creatinine with the latest follow-up values. We evaluated the slope of creatinine clearance, calculated by the Cockcroft and Gault formula,2Cockroft DW Gault MH Prediction of creatinine clearance from serum creatinine.Nephron. 1976; 16: 31-41Crossref PubMed Scopus (12989) Google Scholar and plotted the values against time before and after stent placement.Serum concentrations of creatinine fell from a median of 3·6 (range 1.4–7.8) mg/dL to 1.5 (0.9–2.0) mg/dL in five patients, stabilised from 1.8 (1.3–2.3) mg/dL to 1.6 (1.4–2.8) mg/dL in three patients, and rose from 4.8 (1.6–8.5) mg/dL to 8.5 (7.0–10.0) mg/dL in four patients who were started on dialysis 7, 8 34 and 38 months after stent placement, respectively. The decline of creatinine clearance was significantly slower after stent placement than before (-1.6 [-3.7 to -0.2]) vs -0.004 [-0.89 to 1.1] mL min−1 month−1, p=0.0051 Wilcoxon rank test). Systolic arterial pressure was significantly reduced after stent insertion than before (170 [150–200]) vs 155 [135–190] mm hg, p=0.026). After placement of stents, the number of antihypertensive drugs prescribed fell from 2.5 (1–4) to 2.0 (1–3) (p=0.06).Our findings confirm that renal-artery stent placement slows progression of renal failure in most patients with ischaemic nephropathy and may postpone the need for dialysis. In response to Harden and colleagues' report,1Harden PN MacLeod MJ Rodger RSC et al.Effect of renal-artery stenting on progression of renovascular renal failure.Lancet. 1997; 349: 1133-1136Summary Full Text Full Text PDF PubMed Scopus (406) Google Scholar we describe our experience of renal-artery stenting. 12 patients (eight men) with a median age of 73 (range 56–78) years were treated consecutively with renal-stent placement from April, 1992, and followed up for at least 6 months. Five patients had a bilateral renal-artery stenosis and five had renal-artery stenosis in either surgical or functional solitary kidneys. 17 kidneys were revascularised with Palmaz stents (Johnson and Johnson Interventional Systems, Warren, NJ, USA). Technical success was achieved in all patients. One patient required surgical repair for a pseudoaneurysm at the femoral artery puncture site. Patients were followed every 6 months with duplex sonography, and in two cases with angiography after 12 months and 38 months, respectively. There was no evidence of a significant restenosis in any patient. Follow-up ranged from 2 months to 87 months before stenting (median 7 months), and from 7 months to 56 months thereafter (median 30.5 months). We assessed renal outcomes by comparison of prestenting serum concentrations of creatinine with the latest follow-up values. We evaluated the slope of creatinine clearance, calculated by the Cockcroft and Gault formula,2Cockroft DW Gault MH Prediction of creatinine clearance from serum creatinine.Nephron. 1976; 16: 31-41Crossref PubMed Scopus (12989) Google Scholar and plotted the values against time before and after stent placement. Serum concentrations of creatinine fell from a median of 3·6 (range 1.4–7.8) mg/dL to 1.5 (0.9–2.0) mg/dL in five patients, stabilised from 1.8 (1.3–2.3) mg/dL to 1.6 (1.4–2.8) mg/dL in three patients, and rose from 4.8 (1.6–8.5) mg/dL to 8.5 (7.0–10.0) mg/dL in four patients who were started on dialysis 7, 8 34 and 38 months after stent placement, respectively. The decline of creatinine clearance was significantly slower after stent placement than before (-1.6 [-3.7 to -0.2]) vs -0.004 [-0.89 to 1.1] mL min−1 month−1, p=0.0051 Wilcoxon rank test). Systolic arterial pressure was significantly reduced after stent insertion than before (170 [150–200]) vs 155 [135–190] mm hg, p=0.026). After placement of stents, the number of antihypertensive drugs prescribed fell from 2.5 (1–4) to 2.0 (1–3) (p=0.06). Our findings confirm that renal-artery stent placement slows progression of renal failure in most patients with ischaemic nephropathy and may postpone the need for dialysis.