Use of renin-angiotensin inhibitors in people with renal artery stenosis.

BACKGROUND AND OBJECTIVES: People with atherosclerotic renal artery stenosis may benefit from renin-angiotensin inhibitors, angiotensin-converting enzyme inhibitors, and angiotensin-receptor blockers, but little is known about the factors associated with their use. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The Cardiovascular Outcomes in Renal Atherosclerotic Lesions study (ClinicalTrials.gov identified: NCT00081731) is a prospective, international, multicenter clinical trial that randomly assigned participants with atherosclerotic renal artery stenosis who received optimal medical therapy to stenting versus no stenting from May 2005 through January 2010. At baseline, medication information was available from 853 of 931 randomly assigned participants. Kidney function was measured by serum creatinine-based eGFR at a core laboratory. RESULTS: Before randomization, renin-angiotensin inhibitors were used in 419 (49%) of the 853 participants. Renin-angiotensin inhibitor use was lower in those with CKD (eGFR<60 ml/min per 1.73 m(2)) (58% versus 68%; P=0.004) and higher in individuals with diabetes (41% versus 27%; P<0.001). Presence of bilateral renal artery stenosis or congestive heart failure was not associated with renin-angiotensin inhibitor use. Although therapy with renin-angiotensin inhibitors varied by study site, differences in rates of use were not related to the characteristics of the site participants. Participants receiving a renin-angiotensin inhibitor had lower systolic BP (mean ± SD, 148 ± 23 versus 152 ± 23 mmHg; P=0.003) and more often had BP at goal (30% versus 22%; P=0.01). CONCLUSIONS: Kidney function and diabetes were associated with renin-angiotensin inhibitor use. However, these or other clinical characteristics did not explain variability among study sites. Patients with renal artery stenosis who received renin-angiotensin inhibitor treatment had lower BP and were more likely to be at treatment goal.

Potential risk for intra-aortic balloon-induced obstruction to the celiac axis or the renal artery in the Asian population.

To evaluate the potential risk for intra-aortic balloon (IAB)-induced obstruction to the celiac axis (CA) or the renal artery (RA) when IAB size is chosen according to patient height and the tip is placed 2 cm distal to the origin of the left subclavian artery (LSCA), the computed tomography images of 150 Asian adults were reviewed to identify the distance from the LSCA to the CA (LSCA-CA) and to the RA (LSCA-RA). The diameter of the aorta at the level of the T9 vertebra, CA, and RA was also measured. The length and caliber of the IAB was selected according to two manufacturer's recommendations (Datascope Corp and Tokai Medical Products). The Datascope IAB potentially blocked the CA in 84 % and the RA in 66 %, while the Tokai IAB obstructed the CA in 61 % and the RA in 10 % of cases. The caliber of the IAB overlying the orifice of the RA was longer than the diameter of the aorta in 5 cases (3.3 %) using the Datascope IAB, and in 1 case (0.7 %) using the Tokai IAB. When placing an IAB selected based on patient height, the IAB could obstruct the orifice of the CA and RA in the majority of Asian patients, especially a Datascope IAB.

Renal artery stenosis in minority patients undergoing diagnostic cardiac catheterization: prevalence and risk factors.

BACKGROUND: Atherosclerotic renal artery stenosis (RAS) is a frequently overlooked clinical entity that can cause progressive renal failure and uncontrolled hypertension. Revascularization of a stenosed renal artery is associated with improved clinical outcomes including the prevention of renal failure. Thus, it is important to recognize all potential candidates for renal artery revascularization. In a general population referred for diagnostic cardiac catheterization, RAS of any severity was found in 30% of patients and significant stenosis (> or = 50% diameter narrowing) was found in 15% of patients. The number of minority groups is increasing in the US population, and RAS in this population is not well investigated. Our purpose was to determine the prevalence and risk factors associated with RAS in minority patients referred for diagnostic cardiac catheterization. METHODS: Abdominal aortography was performed in 171 consecutive minority patients referred for diagnostic cardiac catheterization (hispanics = 115, African Americans = 56). The association of clinical and angiographic variables with RAS was examined using univariate and multivariate logistic regression analyses. RESULTS: Renal artery stenosis of any severity was identified in 13.5% of patients (unilateral 7.7%, bilateral 5.8%). Significant RAS was found in 7.7% of patients (unilateral 4.8%, bilateral 2.9%). Independent predictors of RAS included age (mean +/-1SD, 68 +/-10 vs 57 +/-12 yr, P < 0.001, for patients with vs without RAS), coronary artery disease, and elevated serum creatinine levels (> 115 micromol/L). Race/ethnicity (hispanics vs African Americans), sex, smoking, congestive heart failure, diabetes mellitus, peripheral vascular disease, and hypertension were not independent predictors. CONCLUSIONS: Renal artery stenosis in minority patients undergoing diagnostic cardiac catheterization is less common than reported in white patients, is similar in hispanics and African Americans, and is similar in women and men. The clinical and angiographic features are helpful in predicting its presence.

Renal artery repair in African-Americans.

PURPOSE: This retrospective review examines the results of atherosclerotic renal artery (RA) repair in consecutive hypertensive African-Americans treated at our center and compares these results with Caucasians treated during the same period. METHODS: From Jan. 1987 through Sep. 1996, a total of 485 patients underwent operative RA repair. Of these, 28 African-Americans and 370 Caucasians were managed for atherosclerotic renovascular disease. These cohorts were compared on the basis of preoperative blood pressure and renal function, extent of renal disease, extrarenal atherosclerosis, response to operation, and estimated survival. RESULTS: The African-American cohort included nine men and 19 women (mean age, 62 years) with hypertension (mean blood pressure, 204 +/- 31/109 +/- 20 mm Hg) for an average of 10.2 +/- 7.5 years. Ischemic nephropathy (serum creatinine level, > 1.3 mg/dl) was present in 82% (n = 23) of the African-American group. RA reconstructions were unilateral in nine patients and bilateral in 19 patients (including repair to two solitary kidneys), for a total of 45 RA reconstructions (30 RA bypass procedures; eight transrenal/transaortic RA endarterectomy procedures; two RA reimplantations; five nephrectomies). Nine patients underwent combined aortic procedures (four abdominal aortic aneurysm; five occlusive disease). There was one perioperative death in the African-American group as a result of sepsis and multiple organ failure. Among surgical survivors, 20 African-American patients (74%) had a beneficial hypertension response (7% cured, 67% improved). Mean estimated glomerular filtration rate improved significantly from 34 to 42 ml/min/1.73 m2 (p < 0.001). In the 23 patients with ischemic nephropathy, 13 (57%) demonstrated greater than 20% decrease in serum creatinine level. In comparison with the 370 Caucasians (191 men, 179 women), the African-American cohort had significantly more preoperative heart disease (congestive heart failure or left ventricular hypertrophy; 68% vs 46%; p = 0.03) and tended toward more severe renal dysfunction (mean serum creatinine level, 2.5 vs 2.1 mg/dl; p = 0.25). However, African-Americans demonstrated a beneficial blood pressure and renal function response after operation, similar to Caucasians. CONCLUSIONS: Our results indicate that the majority of selected African-Americans have a favorable blood pressure and renal function response to operative renal artery repair. This beneficial clinical response appears equivalent to the response observed in Caucasian patients and supports the search for RA disease in hypertensive African-Americans.

Takayasu arteritis in Israel--update.

Takayasu disease in our Israeli series consists of 56 patients, and has been detected only in Sephardic and oriental Jews as well as in Arabs and Bedouin. Suspicion of Takayasu disease should be raised whenever renal artery stenosis and involvement of the aorta and its branches occur in patients from oriental origin.

Epidemiologic and clinical comparison of renal artery stenosis in black patients and white patients.

PURPOSE: This study was undertaken to compare the epidemiologic and clinical features of renal artery stenosis (RAS) in black patients and white patients. METHODS: Data on all patients identified with 50% or greater RAS from 1984 to 1990 were collected and analyzed. The study was conducted at the Cleveland Clinic Foundation, which is a referral center for patients with renal artery disease. Eight hundred nineteen patients with RAS were identified from an institutional registry that records information on patients with this disease. This group comprises 40 black patients (4.9%) and 779 white patients (95.1%). The presence of RAS was determined by abdominal aortography in all patients. Black patients and white patients with RAS were compared with respect to their age, sex, presence and severity of hypertension, renal function, type and extent of renal artery disease, extrarenal vascular disease, and risk factors such as history of smoking, diabetes, and hyperlipidemia. RESULTS: The mean age of black patients and white patients was 62 years; however, a greater proportion of black patients were women (p = 0.01). RAS was due to atherosclerosis in 95% and 92% of blacks and whites, respectively. Although the extent and severity of RAS were equivalent in black patients and white patients, more blacks were diagnosed with severe (p = 0.01) or refractory (p = 0.05) hypertension. Extrarenal vascular disease was present in 95% and 70% of blacks and whites, respectively (p < 0.01). The incidence of coronary artery disease (p < 0.01), cerebrovascular disease (p < 0.01), and peripheral vascular disease (p < 0.01) was greater among black patients. A history of smoking was more common among black patients (p < 0.01). Serum total cholesterol and low-density lipoprotein cholesterol levels were equivalent among black patients and white patients; however, black patients had higher high-density lipoprotein cholesterol (p = 0.03) and lower triglyceride (p < 0.01) levels. CONCLUSIONS: There are significant differences between black patients and white patients with RAS. The basis for these findings and their relationship to the cause and true prevalence of RAS in blacks requires further study.