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A case of atherosclerotic renal artery stenosis involving successful withdrawal from hemodialysis after percutaneous transluminal renal artery stenting

2016; Elsevier BV; Volume: 223; Linguagem: Inglês

10.1016/j.ijcard.2016.08.050

1874-1754

Toshiki Sawai, Mika Fujimoto, Takayasu Ito, Tomohiro Murata, Eiji Ishikawa, Masaaki Ito,

Vascular anomalies and interventions

We report a case of atherosclerotic renal artery stenosis involving successful withdrawal from hemodialysis after percutaneous transluminal renal artery stenting. A 71-year-old male, with a history of refractory hypertension, polyarteritis nodosa and chronic renal disease was admitted to our hospital with pneumonia and congestive heart failure. On admission, he was taking nine anti-hypertensive agents daily (amlodipine: 10 mg, benidipine: 8 mg, telmisartan: 40 mg, torasemide: 8 mg, trichlormethiazide: 1 mg, bisoprolol: 1.25 mg, doxazosin: 12 mg, methyldopa: 250 mg, and isosorbide dinitrate tape: 40 mg). The patient's pneumonia was successfully cured with antibiotics, and his heart failure was improved with carperitide and diuretics, but his renal function gradually worsened, and his serum creatinine level increased from 3.35 mg/dl on admission [estimated glomerular filtration rate (eGFR): 20.5 ml/min/1.73 m2] to 5.79 mg/dl (eGFR: 8.4 ml/min/1.73 m2) on the 33rd day. The patient's urinary volume decreased and his heart failure recurred so hemodialysis treatment was initiated. Echocardiography detected a normal left ventricular systolic function without significant valvular heart disease. Renal duplex ultrasonography showed an atrophic right kidney (71 mm) and complete obstruction of the renal artery. In addition, the left kidney was normal sized (110 mm), but exhibited a markedly prolonged acceleration time (242 ms), which was strongly suggestive of severe stenosis of the proximal left renal artery. The patient's resistive index of the left kidney was normal (0.71). Total occlusion of the right renal artery and a severe stenotic lesion of the left renal artery were detected on aortography (Fig. 1 A). A Palmatz Genesis stent (5.0 × 15 mm; Cordis Corp., USA) was deployed after pre-dilatation (Fig. 1 B). No device was used for distal protection; however, there were no complication, such as peripheral embolism, and 20 ml of contrast agent were injected. The patient's preoperative urinary volume was just below the diagnostic threshold for anuresis and increased markedly to 2500–3000 ml/day immediately after revascularization. The patient's serum creatinine level also improved considerably. The patient was successfully withdrawn from hemodialysis after about 2 weeks' treatment (Fig. 2). The patient's systolic blood pressure decreased to 130–140 mm Hg (Fig. 3). Most of the anti-hypertensive agents being taken by the patient were withdrawn, and at discharge the patient was taking the following medication: 5 mg amlodipine, 20 mg telmisartan, and 1.25 mg bisoprolol. Before determining the indications of PTRA, it is important to closely examine whether PTRA has anti-hypertensive and/or renoprotective effects. The CORAL, HERCULES and J-RAS trials showed that PTRA achieved better control over the systolic blood pressure than the optimal medical treatment (OMT) [ 1 Cooper C.J. Murphy T.P. Cutlip D.E. Jamerson K. Henrich W. Reid D.M. et al. Stenting and medical therapy for atherosclerotic renal-artery stenosis. N. Engl. J. Med. 2014; 370: 13-22 Crossref PubMed Scopus (649) Google Scholar , 2 Chrysant G.S. Bates M.C. Sullivan T.M. Bachinsky W.B. Popma J.J. Peng L. et al. Proper patient selection yields significant and sustained reduction in systolic blood pressure following renal artery stenting in patients with uncontrolled hypertension: long-term results from the HERCULES trial. J Clin Hypertens (Greenwich). 2014; 16: 497-503 PubMed Google Scholar , 3 Fujihara M. Yokoi Y. Abe T. Soga Y. Yamashita T. Miyashita Y. et al. Clinical outcome of renal artery stenting for hypertension and chronic kidney disease up to 12 months in the J-RAS study — prospective, single-arm, multicenter clinical study. Circ. J. 2015; 79: 351-359 Crossref PubMed Scopus (26) Google Scholar ]. However, no clinical trials have shown that PTRA is superior to OMT in terms of its renoprotective effects [ 1 Cooper C.J. Murphy T.P. Cutlip D.E. Jamerson K. Henrich W. Reid D.M. et al. Stenting and medical therapy for atherosclerotic renal-artery stenosis. N. Engl. J. Med. 2014; 370: 13-22 Crossref PubMed Scopus (649) Google Scholar , 2 Chrysant G.S. Bates M.C. Sullivan T.M. Bachinsky W.B. Popma J.J. Peng L. et al. Proper patient selection yields significant and sustained reduction in systolic blood pressure following renal artery stenting in patients with uncontrolled hypertension: long-term results from the HERCULES trial. J Clin Hypertens (Greenwich). 2014; 16: 497-503 PubMed Google Scholar , 3 Fujihara M. Yokoi Y. Abe T. Soga Y. Yamashita T. Miyashita Y. et al. Clinical outcome of renal artery stenting for hypertension and chronic kidney disease up to 12 months in the J-RAS study — prospective, single-arm, multicenter clinical study. Circ. J. 2015; 79: 351-359 Crossref PubMed Scopus (26) Google Scholar , 4 Wheatley K. Ives N. Gray R. Kalra P.A. Moss J.G. Baigent C. et al. Revascularization versus medical therapy for renal-artery stenosis. N. Engl. J. Med. 2009; 361: 1953-1962 Crossref PubMed Scopus (937) Google Scholar , 5 Bax L. Woittiez A.J. Kouwenberg H.J. Mali W.P. Buskens E. Beek F.J. et al. Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function: a randomized trial. Ann. Intern. Med. 2009; 150 (W150-841): 840-848 Crossref PubMed Scopus (539) Google Scholar ]. Therefore, a case-sensitive approach to the treatment of ARAS is required. There have been several reports about the factors that can be used to predict the effects of PTRA. Progressive renal disease, bilateral ARAS, a solitary functional kidney, a resistive index of <0.8, the absence of an atrophic kidney, and the absence of distal embolization at the time of the PTRA procedure were found to be associated with PTRA-induced renoprotective effects [ 6 Beutler J.J. Van Ampting J.M. Van De Ven P.J. Koomans H.A. Beek F.J. Woittiez A.J. et al. Long-term effects of arterial stenting on kidney function for patients with ostial atherosclerotic renal artery stenosis and renal insufficiency. J. Am. Soc. Nephrol. 2001; 12: 1475-1481 Crossref PubMed Google Scholar , 7 Muray S. Martin M. Amoedo M.L. Garcia C. Jornet A.R. Vera M. et al. Rapid decline in renal function reflects reversibility and predicts the outcome after angioplasty in renal artery stenosis. Am. J. Kidney Dis. 2002; 39: 60-66 Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar , 8 Campo A. Boero R. Stratta P. Quarello F. Selective stenting and the course of atherosclerotic renovascular nephropathy. J Nephrol. 2002; 15: 525-529 PubMed Google Scholar , 9 Edwards M.S. Craven B.L. Stafford J. Craven T.E. Sauve K.J. Ayerdi J. et al. Distal embolic protection during renal artery angioplasty and stenting. J. Vasc. Surg. 2006; 44: 128-135 Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar , 10 Miyashita Y. Ikeda U. Soga Y. Yokoi H. Suzuki K. Inoue N. Results of the retrospective analysis of renal artery stenting for the salvage of renal function study. Angiology. 2014; 65: 620-623 Crossref PubMed Scopus (4) Google Scholar ]. In this case, no distal protection device was used; however, our patient exhibited several of the abovementioned factors. Especially, it is very important to carefully evaluate patients with progressive renal disease with the aim of withdrawing patients from hemodialysis where possible. Murray S et al. showed that rapidly progressive renal failure is associated with a favorable response to PTRA in patients with ARAS [ [7] Muray S. Martin M. Amoedo M.L. Garcia C. Jornet A.R. Vera M. et al. Rapid decline in renal function reflects reversibility and predicts the outcome after angioplasty in renal artery stenosis. Am. J. Kidney Dis. 2002; 39: 60-66 Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar ]. Beutler JJ et al. reported that PTRA had a greater renoprotective effect in patients with declining renal function than in those with stable renal function [ [6] Beutler J.J. Van Ampting J.M. Van De Ven P.J. Koomans H.A. Beek F.J. Woittiez A.J. et al. Long-term effects of arterial stenting on kidney function for patients with ostial atherosclerotic renal artery stenosis and renal insufficiency. J. Am. Soc. Nephrol. 2001; 12: 1475-1481 Crossref PubMed Google Scholar ]. In addition, in this case, ultrasonography demonstrated that the left kidney was normal-sized, and the resistive index was 0.71. These findings suggested that the patient's renal function could be improved using PTRA [ 8 Campo A. Boero R. Stratta P. Quarello F. Selective stenting and the course of atherosclerotic renovascular nephropathy. J Nephrol. 2002; 15: 525-529 PubMed Google Scholar , 11 Radermacher J. Chavan A. Bleck J. Vitzthum A. Stoess B. Gebel M.J. et al. Use of Doppler ultrasonography to predict the outcome of therapy for renal-artery stenosis. N. Engl. J. Med. 2001; 344: 410-417 Crossref PubMed Scopus (669) Google Scholar ]. However, the above predictors have not yet been established; therefore, further studies are required to identify predictors of PTRA-induced renoprotective effects. In conclusion, this report described the successful withdrawal of an ARAS patient with progressive kidney disease from hemodialysis. Providing appropriate case selection is carried out, PTRA can have renoprotective effects as well as blood pressure control. Fig. 2Time-course of creatinine level and urine volume. Show full caption The patient's serum creatinine level was markedly improved after renal artery revascularization. PTRA: percutaneous transluminal renal angioplasty. View Large Image Figure Viewer Download Hi-res image Fig. 3Time-course of blood pressure. Show full caption The patient's blood pressure was markedly improved after renal artery revascularization. PTRA: percutaneous transluminal renal angioplasty, SBP: systolic blood pressure, DBP: diastolic blood pressure. View Large Image Figure Viewer Download Hi-res image The patient's serum creatinine level was markedly improved after renal artery revascularization. PTRA: percutaneous transluminal renal angioplasty. The patient's blood pressure was markedly improved after renal artery revascularization. PTRA: percutaneous transluminal renal angioplasty, SBP: systolic blood pressure, DBP: diastolic blood pressure.