[Renal artery stenosis: do not toss the stent aside]. / Nierarteriestenose: gooi de stent niet zomaar opzij.

Primary stent placement for atherosclerotic renal artery stenosis (ARAS) has become a subject of considerable debate. It even seems that the indication has been cast aside altogether, maybe as a result of prospective trials seeking to define the role of renal revascularisation, which failed to establish a compelling benefit for endovascular stenting when added to effective medical regimens. Various explanations for these disappointing results have been offered. However, it could be that the currently accepted belief, i.e. that only stenoses greater than 50-70% of the luminal surface result in ischaemic changes leading to hypertension and renal insufficiency, needs rethinking. There is ample experimental evidence that ischaemia per se does not fully explain the clinical sequelae accompanying ARAS. Treatment of advanced stenosis and renal derangement might be unsuccessful because the changes resulting from these conditions are already irreversible. Perhaps treatment should be initiated earlier in the disease process when stenosis and renal impairment are less advanced.

[Dutch guideline for cardiovascular risk management: a consensus model]. / Richtlijn cardiovasculair risicomanagement: een poldermodel.

This commentary concerns two major aspects of the guideline, which was revised in 2011 and seems to us the result of a consensus model. The first aspect, namely, of age in relation to cardiovascular risk stratification and the indication that recent studies show that treatment of hypertension of both very old and young people should be considered, is discussed. The second aspect discussed in this commentary, regarding hyperlipidaemia in obesity and diabetes, concerns the argument that apolipoprotein B-100 level or non-HDL cholesterol should specifically be measured for screening and treatment targets.

[Stent or not in the case of renal artery stenosis? No clear-cut answer yet]. / Wel of geen stent bij een nierarteriestenose? Het pleit is nog niet beslecht.

Recent trials, STAR and ASTRAL, indicate that medicinal treatment alone is as good as stenting plus medicinal treatment in preventing renal events in patients with atherosclerotic renal artery stenosis of more than 50-70%. In this commentary, it is stated that the high number of complications in catheter interventions is related to the generalised atherosclerosis in these patients. In this group of patients intervention is too late to prevent renal events. Stenting in patients with low-grade renal artery stenosis should be considered as an option for treating hypertension and atherosclerotic renal artery stenosis. This should be studied in a prospective randomised controlled trial.