Patient Selection for Revascularization of Atherosclerotic Renal Artery Stenosis: Comparing the Importance of Stenosis Severity and Clinical Phenotype.

RATIONALE &

OBJECTIVE

Trials failed to show that angioplasty and stenting of atherosclerotic renovascular disease (ARVD) conferred benefit when used as first-line therapy. However, some patients might benefit from kidney revascularization depending on their clinical phenotype and severity of renal artery stenosis (RAS). We investigated this hypothesis further.

STUDY

DESIGN

Data from the Angioplasty and Stenting for Renal Artery Lesions (ASTRAL) randomized trial and Salford ARVD observational study were included in a single analysis.

SETTING &

PARTICIPANTS

Patients were grouped based on RAS severity (≥70%) and whether unilateral or bilateral, with the bilateral group including RAS in a single functioning kidney. High-risk clinical phenotypes included advanced chronic kidney disease (CKD) (estimated glomerular filtration rate < 30 mL/min/1.73 m2), rapid CKD progression (creatinine increase >100 μmol/l or >20% per year), refractory systolic hypertension (≥150 mm Hg on ≥3 agents), and heart failure (chronic or decompensated).

EXPOSURES: Medical therapy alone versus medial therapy and kidney revascularization.

OUTCOME: Composite of end stage CKD, cardiovascular events, or all-cause mortality.

ANALYTICAL APPROACH: Cox proportional hazard model adjusted for age, self-reported gender, and estimated glomerular filtration rate. Analysis of all patients and selected subgroups.

RESULTS

In total, 1,644 patients (806 ASTRAL and 838 Salford). Median (IQR) age 72 (66-77) years. For bilateral severe RAS (≥70%) the HR for the composite outcome for revascularization compared with medical therapy was 0.70 (0.50-0.99), P = 0.048. The clinical phenotype where benefit appeared to be greatest in the presence of bilateral severe disease was people with rapidly progressive kidney disease with a HR of 0.39 (0.22-0.71]). In the absence of bilateral severe RAS, there was no benefit to revascularization for any clinical phenotype.

LIMITATIONS: The analyses included observational data.

CONCLUSIONS

The presence of bilateral severe RAS may be the best predictor of benefit for kidney revascularization.