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Percutaneous Renal Artery Interventions / Albertal et al
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Differently to Percutaneous RenalArtery Interventions?
M. Albertal, MD, PhD, G. Nau, MD, L. T. Padilla, MD,F. A. Cura, MD, PhD, J. Thierer, MD, and J. A. Belardi, MD
Background: Women have higher risk of contrast-
a significant improvement in GFR and systolic blood
induced nephropathy than men. The purpose of this
pressure, while females did not. The presence of severe
study was to determine the relative impact of gender
CKD and male gender were the only predictors of long-
on long-term renal function after percutaneous renal
term GFR improvement. Conclusion: Male patients
interventions (PRI). Methods and Results: We included
and patients with poor baseline renal function showed
all patients undergoing PRI. Men (n ¼ 72) and women
an important benefit with PRI, suggesting that it is
(n ¼ 28) had similar age, men had more diabetes, cor-
not too late for renal revascularization if properly
onary and peripheral artery disease, higher serum crea-
tinine and similar glomerular filtration rate (GFR), andprevalence of chronic kidney disease (CKD) stage !3
renal artery stenosis; gender; angioplasty;
when compared with females. At follow-up, men had
Therefore, the aim of our study was to compare
long-term renal function outcome in men and
Renal artery stenosis is a recognized cause of chronic
kidney disease (CKD)1-4 and conveys significant riskof cardiac morbidity and mortality.5,6 Percutaneousrenal artery intervention (PRI) carries the potential
for renal function preservation and even improve-ment if properly indicated.1,7-10 Recent reports indi-
We retrospectively reviewed a subset of 100 consec-
cate that women are specifically prone to renal injury
utive patients with de novo renal artery stenosis who
after contrast exposure.11,12 Women’s clinical bene-
underwent single or bilateral PRI from January 1999
fit expected by PRI can potentially be offset by the
to October 2007. Data were prospectively collected
development of contrast-induced injury. After PRI,
in a dedicated database from the interventional car-
a link between renal function preservation and gen-
diology department at the Instituto Cardiovascular
de Buenos Aires, Buenos Aires, Argentina. Percuta-neous renal intervention was performed in patientswith significant angiographic stenosis (diameter ste-nosis of !70%). Percutaneous renal interventionwas performed either (1) as a result of an incidentalangiographic finding, (2) in patients with a positive
From the Research Department (MA, JT), and Department ofInterventional Cardiology and Endovascular Therapeutics (GN,
noninvasive imaging test, (3) due to uncontrolled
LTP, FAC, JAB), Instituto Cardiovascular de Buenos Aires,
hypertension, or (4) unexplained CKD. The preinter-
Ciudad Auto´noma de Buenos Aires, Argentina.
ventional workup and follow-up visits included mea-
Address correspondence to: M. Albertal, Research Department,
surement of serum creatinine and systolic blood
Instituto Cardiovascular de Buenos Aires, Blanco Encalada
pressure (SBP) and diastolic blood pressure (DBP)
1543, Ciudad Auto´noma de Buenos Aires, Argentina; e-mail:firstname.lastname@example.org.
and number of antihypertensive drugs.
Baseline Characteristics of the Study Population According to Gender
NOTE: CKD ¼ chronic kidney disease.
Glomerular filtration rate (GFR) was calculated
using the modification of diet in renal disease equation(MDRD;mL/minper1.73m2):186Â (serumcreatinine
Patient demographics are detailed in Table 1.
in mg/dL)À1.154 Â (age)À0.203 Â (0.742 for women).
Although age and proportion of hypertension was
Percutaneous renal intervention was performed
similar between groups, females (n ¼ 28) had a lower
as previously described.8 In 22 patients, we per-
proportion of comorbid conditions including dia-
formed bilateral renal artery stenting. Dual antipla-
betes mellitus, coronary, and peripheral artery dis-
telet therapy was started at least the day before
ease. Baseline serum creatinine was significantly
intervention and routinely consisted of 75 mg of clo-
lower in females, but GFR values and prevalence of
pidogrel daily for 4 weeks and 100 mg of aspirin
chronic renal failure (CKD stage !3) were similar
indefinitely. Immediately before the intervention,
in both groups. Females had less proportion of
we administered a fixed bolus dose of 5000 IU of
patients undergoing stenting, whereas bilateral PRI
was performed in similar proportion in both groups.
The primary end point was the proportion of
patients with !20% GFR improvement at follow-up. As secondary end points, we assessed the propor-
tion of patients with !20% GFR decline prior to hos-
pital discharge and at follow-up visit, average
Median follow up was 1.7 years (25%-75% IQ 1.2-
reduction in number of antihypertensive drugs, aver-
2.7 years). Systolic blood pressure decreased signifi-
age reduction in SBP and/or DBP at follow-up.
cantly in both groups, mean SBP reduction was 5.2%in males and 3.4% in females, P ¼ .663; Figure 1).
Diastolic blood pressure and the number of antihy-pertensive drugs did not vary in either group.
Data were expressed as mean + standard deviationor median, and interquartile (IQ) range values wereused for continuous variables. Categorical data were
expressed as percentages. Student t test and 2 test
were used to make comparisons between the men
and the women. The nonparametric Wilcoxon ranksum test was used to compare continuous variables
A total of 89 of 100 patients had postprocedural
when the data were not normally distributed. Multi-
serum creatinine available. Acute in-hospital GFR
variate logistic regression analysis was performed to
decline (!20%) was observed in 15.7 % (14/89) of
predict (a) !20% GFR improvement, and (b)
the patients. Acute decline in GFR was more fre-
!20% GFR decline, both at follow-up visits. A P <
quent in patients who exhibit long-term decline in
GFR [35.7% (5/14) vs 9.5% (7/74), P ¼ .021],
Percutaneous Renal Artery Interventions / Albertal et al
139.7 139.5 140.3
129.7 129.3 130.7
* P > .005 vs Baseline
SBP, DBP, serum creatinine, and GFR changes at follow-up. Note that SBP and renal function parameters improved in
the overall and male populations, while no improvement was observed in females. DBP indicates diastolic blood pressure; FUP ¼
follow-up; GFR ¼ glomerular filtration rate; SBP ¼ systolic blood pressure.
whereas there was no association between acute
16.2; 95% CI 4.3-105.8, P > .001) as independent
decline and long-term improvement. In addition,
neither gender type nor the degree of CKD corre-
Multivariate analysis to predict GFR decline at
lated with acute in-hospital GFR decline.
follow-up identified CKD stage !3 (OR 0.07; 95%
Forty-eight percentage of patients improved their
CI 0.017-0.25, P ¼ .0001), male gender (OR 0.14,
GFR at follow-up, whereas 20% had a substantial
95% CI 0.03-0.59, P ¼ .007) as independent predic-
decline in their GFR. Improvement in GFR was less
tors of GFR decline at follow-up. Age, diabetes mel-
common in females than men (Figure 2) and more
litus, basal SBP and DBP values, and number
common in patients with CKD stage !3 than in
of antihypertensive drugs were not independent
patients with milder CKD or normal GFR (Figure 3).
predictors of either improvement or decline at
Patients with and without baseline statin use had sim-
ilar GFR improvement rate (22% vs 17.9%, P ¼ .38).
In contrast, GFR decline at follow-up was more
frequent in women than in men and less common
in patients with CKD stage !3 than in earlier CKDstages (Figures 2 and 3).
In our study, almost half of our population had a
To identify predictors of GFR improvement, we
clinically meaningful improvement in GFR, espe-
performed a multivariate logistic analysis and identi-
cially in men and in patients with severe CKD.
fied the presence of CKD stage !3 (OR 29.6; 95%
Females were associated with more frequent decline
CI 8.3-105.8, P > .001) and male gender (OR
Improve (≥20% increase in GFR)
Worse (≥20% decline in GFR)
* P < .001 vs Females
GFR response at follow-up is shown in the overall population (above) and according to gender (below). Note that males
showed a greater proportion of patients with !20% GFR improvement than females. GFR indicates glomerular filtration rate.
CKD stage 0-2
CKD stage 3-5
*P < .001 vs Stage 3-5
GFR response at follow-up is shown according to baseline renal function. Note that patients with baseline significant
renal impairment achieved greater benefit. CKD indicates chronic kidney disease; GFR ¼ glomerular filtration rate.
Atherosclerotic renal artery stenosis is quite pre-
American College of Cardiology meeting in 2008
valent worldwide,13-15 especially in patients with
clearly indicated that stenting these lesions does not
atherosclerosis in other vascular beds. Preliminary
result in any improvement in blood pressure and/or
results from the ASTRAL trial presented in the
renal function when compared with optimal medical
Percutaneous Renal Artery Interventions / Albertal et al
therapy.16 Thus, current indication on ARAS stent-
definitively conclude that blood loss did not impact
ing is to say the least, controversial. In an attempt
GFR values, as a result renal hypoxic insult. Fourth,
to predict clinical benefit after PRI, several investiga-
postprocedural GFR was not mandatory in our study.
tors have evaluated the adjunctive use of different
It is possible that primary physicians ordered such
laboratory test (ie, serum creatinine) in those
Doppler-derived resistance index, use of brain
patients, in whom they feel were at greater risk for
natriuretic peptide levels, measuring renal frame
developing contrast-induced nephropathy, generat-
count, and renal blush).17-19 From all these para-
ing a potential bias. The latter prevents an accurate
meters, fractional flow reserve may be the more
estimation of the procedural renal risk.
accurate predictor of lesion hemodynamic severity
Despite these above-mentioned limitations, our
and blood pressure response. However, it is not avail-
results suggest that women had a lower benefit from
able in every laboratory and it is possible to have
PRI, while patients with severe CKD had greater
essential hypertension and later developed a hemo-
chances for renal function improvement or stabiliza-
dynamically significant renal artery stenosis. This
latter case may not necessarily derive benefit fromPRI. Several studies have suggested that patientswith bilateral renal artery stenosis or with concomi-tant renal impairment derive benefit from PRI.7 In
line with previous studies, 70.5% (43/61) of ourpatients with CKD !3 improved their GFR with only
1. Watson PS, Hadjipetrou P, Cox SV, Piemonte TC,
6.6% (4/61) of these patients exhibiting a meaningful
Eisenhauer AC. Effect of renal artery stenting on renalfunction and size in patients with atherosclerotic reno-
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Previous studies have shown that women experi-
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ence greater GFR decline after contrast expo-
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sure.11,12,20,21 Evidence from animal and human
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3. Schreiber MJ, Pohl MA, Novick AC. The natural history
larger total glomerular volume than females,22 which
of atherosclerotic and fibrous renal artery disease. Urol
may provide males with greater protection against
nephrotoxicity, ischemic-related injury, and also
4. Zierler RE, Bergelin RO, Isaacson JA, Strandness DE Jr.
hyperfiltration. In addition, postmenopausal women
Natural history of atherosclerotic renal artery stenosis: a
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Surg. 1994;19(2):250-257;discussion 257-258.
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The present study represents a retrospective view
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a prospectively collected data at a single institution.
In our study, several limitations deserve to be men-
6. Isles C, Main J, O’Connell J, et al. Survival associated
tioned. First, there are no data available regarding
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collaborative study. Scott Med J. 1990;35(3):70-73.
ted to prevent contrast-induced nephropathy (eg,
7. Bates MC, Campbell JE, Broce M, Lavigne PS,
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Riley MA. Serum creatinine stabilization following renal
tions such as N-acetylcysteine). Second, baseline
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8. Dorros G, Jaff M, Mathiak L, et al. Renal function and
survival after renal artery stent revascularization maybe influenced by embolic debris. J Invasive Cardiol.
(NSAIDs) or metformin have not been recorded. The
latter may be relevant because prior use of NSAIDs
9. Harden PN, MacLeod MJ, Rodger RS, et al. Effect of
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renal failure. Lancet. 1997;349(9059):1133-1136.
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10. Zeller T, Frank U, Muller C, et al. Predictors of improved
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plasty of severe atherosclerotic ostial renal artery steno-
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sis. Circulation. 2003;108(18):2244-2249.
11. Sidhu RB, Brown JR, Robb JF, et al. Interaction of gen-
20. Gill NK, Piccione EA, Vido DA, Clark BA, Shannon RP.
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21. Mueller C, Buerkle G, Perruchoud AP, Buettner HJ.
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23. Tada Y, Ichihara A, Koura Y, et al. Ovariectomy
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enhances renal cortical expression and function of
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