Ischemic nephropathy incidental vascular lesions can be Identified
Ischemic nephropathy
…‘incidental’ vascular lesions can be Identified in 3 -5% of normotensive subjects… Lorenz EC, et al Clin J Am Soc Nephrol 2010; 5: 431 -438
Resistive index: an ideal test for renovascular disease or ischemic nephropathy? RI>0. 80 : διαγνωστικός για νεφραγγειακή υπέρταση? OXI διότι αυξάνεται και σε: ·Μεγάλη ηλικία ιδίως σε υπερτασικούς ·Διαβητική νεφροπάθεια ·Οξεία νεφρική ανεπάρκεια ·Απόφραξη αποχετευτικού συστήματος ·Νεφροπάθεια ΣΕΛ κ. λ. π. …Although the absolute value of the resistive index is of little utility in diagnosing Renal artery stenosis, a difference of at least 5% in resistive index between the kidneys Can indicate renal artery stenosis on the side with the lower value but should not be The only parameter used for diagnosis… ►Iσως να είναι χρήσιμος για παρακολούθηση μετά την παρεμβατική διόρθωση της βλάβης ►Προγνωστικός δείκτης βιωσιμότητας του νεφρού μετά την παρέμβαση Jorg Radermacher. Nat Clinic Practice Nephrol, 2006; 2: 232 -233
Bold Oxygen Level-Dependent (BOLD) MRI MR and CT angiogram
Hypertens 2010; 56: 525 -532
Hypertens 2010; 56: 525 -532 1616 patients(angioplasty) 1014 patients(surgery) 46% cured 58% cured
Hypertens 2010; 56: 525 -532 The pobability of cure was negatively associated with: age, duration of hypertension, medial type FMD Negative trend in the cure rate in the bilateral group
‘…I don’t know anybody that’s certain about anything! There is no right or wrong answer, this is controversial…’ Τextor 2008
• Medical treatment vs Revascularization (randomised trials) • Retrospective studies(medical therapy) • Retrospective studies(stent-angioplasty)
Medical therapy vs Revascularization
Retrospective studies
S. Ziakka, et al. J of Renovasc Hypertansion 2006; 4: 1 -5
• Retrospective studies(medical therapy)
…The medical management of people with renovascular disease ought to include an ACE and an ARB… Textor 2008 Aντιμετώπιση συνολικού καρδιαγγειακού κινδύνου (στατίνη, ασπιρίνη, αλλαγή του τρόπου ζωής)
Retrospective studies (PTA-STENT)
Τextor 2008
Management of renovascular hypertension and ischemic nephropathy Hypertension±reduced GFR Initiate therapy: antihypertensive medications, lifestyle, risk factor, dislipide managementmia Suspicion of renovascular disease: ? Age, associated vascular disease, diminishing GFR, ? Clinical features/abrupt onset high low PTA negative Deteriorating kidney function Uncontrolled hypertension Indications for revascularization Circulatory congestion (bilateral high-grade RAS Solitary functioning kidney) progression Stable renal function excellent BP PTRA/STENT Repeat assessment: 3 -6 mos Stable renal function Excellent BP May need repeat procedure no Repeat assessment: 6 -12 ws ? BPcontrol ? stable renal function Optimize antihypertensive and medical therapy Recheck for vessel patency ? restenosis ? technical failure ? de-novo contralateral lesions ? atheroemboli Τextor 2008
CORAL NITER STAR
November 2009; 361: 1953 -62
November 2009; 361: 1953 -62
November 2009; 361: 1953 -62
? ‘Drive by shooting’ is the term used by nephrologists in the USA to describe the practice of cardiologists in performing renal angiography and placing stents if ARAS is present. ‘Drive by shooting’ has obvious economic indications but does highlight the situation when technology provides procedures for which the clinical indication is unclear. J E Scoble, Journal of Renovasc Disease, 2009
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