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NDT Advance Access originally published online on March 29, 2007
Nephrology Dialysis Transplantation 2007 22(7):1916-1919; doi:10.1093/ndt/gfm130
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© The Author [2007]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Efficacy of renal artery angioplasty and stenting in a solitary functioning kidney

Jackson Tan1, Rafik Filobbos1, Girish Raghunathan2, Tony Nicholson1, Richard Fowler1, Mark Wright1 and David Eadington3

1Leeds General Infirmary, Great George Street, Leeds LS1 3EX, 2St. James Hospital, Beckett Street, Leeds LS9 7TF and 3Hull Royal Infirmary, Anlaby Road, Hull HU3 2JZ, UK

Correspondence and offprint requests to: Dr Jackson Tan, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK. Email: jcstan1810{at}yahoo.co.uk



   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Discussion
 References
 
Objective. The aim of this study was to share our experience of percutaneous renal artery angioplasty and stenting (PTRAS) in our patients with a solitary functioning kidney over a 10-year period.

Methods. The procedures were performed on 75 patients from 1995 to 2004. Data were collected retrospectively from case notes of patients. The definition for solitary functioning kidney was a contralateral kidney size of <8 cm, complete occlusion of contralateral renal artery or previous nephrectomy. Serum creatinine was considered improved or worse if the deviation from the baseline value was >20%.

Results. For the purpose of halting renal deterioration (n = 47), there were improvement and stabilization in 21% and 55% at 3 months and 28% and 28% at 12 months. Systolic blood pressure (n = 27) improvement and stabilization were achieved in 33% and 56% both at 3 and 12 months. Diastolic blood pressure (n = 27) improvement and stabilization were 22% and 70% at 3 months and 33% and 48% at 12 months. Five out of seven patients with acute renal failure (serum creatinine >500 µmol/l and requiring haemodialysis) pre-procedure were dialysis-free at 12 months. Complications occurred in 19 (25%) patients and these included bleeding (n = 16), pseudoaneurysm (n = 3), renal artery dissection (n = 2) and cholesterol embolization (n = 1).

Conclusion. PTRAS in a solitary functioning kidney produced clinical benefits in the majority of patients with resistant hypertension and renal function deterioration.

Keywords: acute renal failure; angioplasty; hypertension; renal artery stenosis; single; solitary; stenting



   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Discussion
 References
 
Atherosclerotic renal artery stenosis (ARAS) is an important cause of renal impairment, hypertension and, rarely, sudden onset pulmonary oedema. Percutaneous renal artery angioplasty, usually now with stenting (PTRAS), is the predominant interventional option. Intervention on a solitary functioning kidney is considered more hazardous, because the contralateral kidney provides no supplemental function, and only limited data supports the use of intervention in these patients. However, revascularization of a solitary functioning kidney might provide more direct evidence of the efficacy of the procedure. At present, there is still no consensus on the best management of renal artery stenosis in a solitary functioning kidney. We, therefore, present our experience of PTRAS in 75 patients with solitary functioning kidneys.



   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Discussion
 References
 
The patients reported were treated in three teaching hospitals between 1995 and 2004, and identified from radiological databases. All patients had ostial atherosclerotic renal artery stenosis diagnosed by percutaneous angiography or magnetic resonance angiography. The definition of a solitary functioning kidney used was a contralateral kidney size of <8 cm length on ultrasound, complete occlusion in the contralateral renal artery, previous nephrectomy or congenital absence of a kidney.

The data was collected from clinical records on a standard proforma including hospital, age at the time of intervention, comorbid conditions, number of antihypertensive medications, indication for the procedure and complications. Serial data were collected for serum creatinine and blood pressure before and after the procedure for a period of up to one year. Improvement of renal function and blood pressure after the procedure was defined as a consistent 20% decrease from the baseline value, deterioration as a consistent 20% increase above baseline and values within 20% of baseline were considered stabilized.

We classified the indication(s) for the procedure into six groups: progressive renal impairment, acute renal failure, resistant hypertension, ‘flash’ pulmonary oedema, to facilitate safer use of ACE inhibitors (for co-existing systolic heart failure) and blockage of a pre-existing stent. Particular attention was given to information regarding dialysis at any point before or after the procedure and mortality from any cause. Technical success of the procedure was defined as the placement of a stent at the desired position. For statistical analysis, descriptive data is expressed as mean ± 1 standard deviation. Differences between groups were calculated by the Student's t-test for continuous variables and by contingency tables for nominal variables. Probability values of <0.05 were considered statistically significant.



   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Discussion
 References
 
A total of 82 procedures were performed on 75 patients. Seven patients required repeat procedures because of re-stenosis, four of whom had deterioration of renal function. These repeat procedures were considered as separate events. Ischaemic nephropathy was regarded as the cause of the solitary functioning kidneys in most patients, but four patients had had a previous nephrectomy and one had a congenital renal absence. The baseline charactaristics of the patients are demonstrated in Table 1.


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  		Table 1. Baseline characteristics

 
The indications for the procedures are shown in Table 2. Some patients had more than one indication for the procedure. Acute renal failure is defined as patients presenting with serum creatinine >500 µmol/l and requiring dialysis prior to intervention. The data for each subset of patients was examined separately, so more objective assessment of the effect of the procedure on that specific indication could be made.


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  		Table 2. Indications for procedures

 
Figures 1–3GoGo illustrate the outcome of the procedure on serum creatinine and blood pressure for the purpose of slowing renal impairment and improving systolic and diastolic blood pressure, respectively.


Figure 1
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  		Fig. 1. Serum creatinine outcome.

 

Figure 2
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  		Fig. 2. Systolic blood pressure outcome.

 

Figure 3
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  		Fig. 3. Diastolic blood pressure outcome.

 
The number of antihypertensive medications taken by patients who had the procedure for blood pressure control were reduced from 3.7 ± 1.3–2.9 ± 1.0 (P < 0.05).

Seven patients had the procedures performed for acute renal failure. All seven patients required dialysis at presentation. Five patients recovered their renal function without needing further dialysis following the procedure up to the 1-year follow-up period. Three of these five patients had been taking ACE inhibitors or Angiotensin II receptor blockers before admission. The two patients who did not recover their renal function both died within one week of the procedure, one from septicaemia and the other from dialysis withdrawal due to frailty and comorbidity. These cases are illustrated in Table 3.


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  		Table 3. Acute renal failure outcome

 
The data for the patients who had the procedure done for pulmonary oedema were not analysed because none of these patients had the procedures done exclusively for this indication and we felt that there is no objective measure that can be used to indicate improvement or deterioration in symptoms.

At 1 year, seven (9.3%) patients had died (two from dialysis withdrawal, two from sepsis, one myocardial infarction and two unknown) and seven (9.3%) patients reached end-stage renal failure. Complications occurred in 19 (25.3%) patients. Sixteen (19.5%) had bleeding episodes of which three (3.7%) required blood transfusion. Other complications included three (3.7%) cases of pseudoaneurysm, two (2.4%) self-limiting renal artery dissection and one (1.2%) cholesterol embolization which required temporary haemodialysis.



   Discussion
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
References
 
Percutaneous renal artery angioplasty and stenting (PTRAS) is often quoted as the mainstay of treatment for atherosclerotic renal artery stenosis. Weibull et al. [1] recommended percutaneous renal artery angioplasty (PTRA) as first choice therapy over surgery for renovascular hypertension, if combined with intensive follow-up and aggressive re-intervention. Van der Ven et al. [2] subsequently reported superior vessel patency when PTRA was combined with stenting and Trude et al. [3] confirmed that PTRAS has a higher technical success rate and a lower re-stenosis rate than PTRA alone (98 vs 77 and 17 vs 26 respectively; P < 0.001). However, randomized controlled trials comparing PTRAS and medical treatment in controlling hypertension suggest no extra benefits [4–6].

Harden et al. [7] reported beneficial slowing in progression of renal failure in patients with a median serum creatinine of 257 µmol/l and a meta-analysis [3] showed that renal function improved in 30% and stabilized in 38% after PTRAS. There is still no completed adequately powered randomized controlled trial testing the value of renal artery revascularization in delaying the progression of renal impairment.

The prevalence of a solitary functioning kidney varied in different studies. Bonelli et al. [8] reported the prevalence of a single functioning kidney in about 4% of the 320 patients who underwent PTRA with them between 1980 and 1993. Gill and Fowler [9] on the other hand had a prevalence of 29% in their study of 100 consecutive patients who had PTRAS between 1993 and 1999. Patient and renal survival at two years for patients with ARAS of single kidney were 47% and 45% respectively compared with bilateral ARAS (82% and 74%) and unilateral ARAS (97% and 96%) [10]. There were only limited studies reporting on the interventions in these patients. Table 4 summarized the literature currently available for these patients.


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  		Table 4. Summary of literature on solitary functioning kidney intervention

 
In trials that directly compare revascularization in both solitary functioning kidneys and bilateral functioning kidneys, results have been variable. Lossino et al. [16] report renal function improvement after revascularization in 48% of patients with renal insufficiency due to bilateral stenosis or stenosis in solitary functioning kidneys compared with none with unilateral stenosis. Gill and Fowler [9] and Rivolta et al. [17], however, report no significant difference in renal function improvement between these two groups.

Our series of patients represented the largest series on the revascularization of the single kidney. Results for the effect of the procedure on renal function deterioration were similar to that of Chatziioannou [13], Bush [14] and Shannon [15], whereby there were approximately one-third of total patients in each of the three groups. Our study also confirmed the benefits on blood pressure control as demonstrated by Sahin [11] and Cioni [12]. As some of the patients in our study were derived from the Gill and Fowler study [9], it was reasonable to draw comparison with the other type of ARAS patients that also participated in that study, of which there was a similar trend in blood pressure and renal function improvement. In addition, this study also showed encouraging results for renal recovery following intervention on acute renal failure which have not been reported in other series before. Major complications relating to the procedures were few and our rate was comparable to the aforementioned studies.

As this is a retrospective study, it was not possible to assemble a control group for result comparisons. We accept that this is a major limitation to the study and even if the study is to be repeated prospectively within our centres, it is difficult to envisage our clinicians not intervening on patients with this potentially curable condition, especially when complication rates are acceptable.

Large randomized studies like ASTRAL [18] and CORAL [19] are in progress to ascertain benefits from PTRAS. Whilst it is useful to have information from these studies particularly regarding factors predicting potential benefits, it is important to emphasize that our patient population is different from theirs. Most of the patients in our study were derived from a higher risk group whereby interventions were deemed necessary, and hence, were not entered into randomized controlled trials. Therefore, it was reasonable to assume that if there were no interventions, these patients would experience further deteriorations in their serum creatinine and blood pressure. On this basis, any stabilization of renal impairment and blood pressure would represent a beneficial outcome.

We conclude that PTRAS offers benefits to most patients with a solitary functioning kidney for renal function preservation and blood pressure control. As there is limited evidence for these patients at present, a decision regarding intervention should be based on a balance of benefits against the relative minor detriments associated with complications.



   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 

  1. Weibull H, Berqvist D, Bergentz SE, Jonson K, Hulthen L, Manhem P. Percutaneous transluminal renal angioplasty versus surgical reconstruction of atherosclerotic renal artery stenosis: prospective randomized study. J Vasc Surg (1993) 18:841–852.[CrossRef][Web of Science][Medline]
  2. van de Ven PJG, Kaatee R, Beutler JJ, et al. Arterial stenting and balloon angioplasty in ostial atherosclerotic renovascular disease: a randomised trial. Lancet (1999) 353:282–286.[CrossRef][Web of Science][Medline]
  3. Leertouwer TC, Gussenhoven EJ, Bosch JL, van Jaarsveld BC, van Dijk LC, Deinum Man in't Veld AJ. Stent placement for renal artery stenosis: where do we stand? A meta-analysis. Radiology (2000) 216:78–85.[Abstract/Free Full Text]
  4. Webster J, Marshall F, Abdalla M, et al. Randomised comparison of percutaneous angioplasty vs continued medical therapy for hypertensive patients with atheromatous renal artery stenosis. J Hum Hypertens (1998) 12:329–335.[CrossRef][Web of Science][Medline]
  5. Plouin PF, Chatellier G, Darne B, Raynaud A. Blood pressure outcome of angioplasty in atherosclerotic renal artery stenosis: a randomized trial. Essai Multicentrique Medicaments vs Angioplastie (EMMA) Study Group. Hypertension (1998) 31:823–829.[Abstract/Free Full Text]
  6. Van Jaarsveld BC, Krijnen P, Pieterman H, et al. The effect of balloon angioplasty on hypertension in atherosclerotic renal-artery stenosis. Dutch Renal Artery Stenosis Intervention Cooperative Study Group. N Engl J Med (2000) 342:1007–1014.[Abstract/Free Full Text]
  7. Harden PN, Macleod MJ, Rofger RS, et al. Effect of renal-artery stenting on progression of renovascular renal failure. Lancet (1997) 349:1133–1136.[CrossRef][Web of Science][Medline]
  8. Bonelli F, McKusick M, Textor S, et al. Renal artery angioplasty: technical results and clinical outcome in 320 patients. Mayo Clin Proc (1995) 70:1041–1052.[Abstract]
  9. Gill K, Fowler R. Atherosclerotic renal arterial stenosis: clinical outcomes of stent placement for hypertension and renal failure. Radiology (2003) 226(Suppl 3):821–826.[Abstract/Free Full Text]
  10. Conolly J, Higgins R, Walters H, et al. Presentation, clinical features and outcome in different patterns of atherosclerotic renovascular disease. QJM (1994) 87:413–421.[Abstract/Free Full Text]
  11. Sahin S, Cimsit C, Andac N, Baltacioglu F, Tuglular S, Akoglu E. Renal artery stenting in solitary functioning kidneys: technical and clinical results. Eur J Radiol (2006) 57:131–137.[CrossRef][Web of Science][Medline]
  12. Cioni R, Vignali C, Petruzzi P, et al. Renal artery stenting in patients with a solitary functioning kidney. Cardiovasc Intervent Radiol (2001) 24(Suppl 6):372–437.[CrossRef][Web of Science][Medline]
  13. Chatziioannou A, Mourikis D, Agroyannis B, et al. Renal artery stenting for renal insufficiency in solitary kidney in 26 patients. Eur J Vasc Endovasc Surg (2002) 23:49–54.[CrossRef][Web of Science][Medline]
  14. Bush R, Martin L, Lin P, et al. Endovascular revascularisation of renal artery stenosis in the solitary functioning kidney. Ann Vasc Surg (2001) 15:60–66.[Web of Science][Medline]
  15. Shannon H, Gillespie I, Moss J. Salvage of the solitary kidney by insertion of a renal artery stent. AJR. Am J Roentgenol (1998) 171:217–222.[Abstract/Free Full Text]
  16. Losinno F, Zuccala A, Busato F, Zucchelli P. Renal artery angioplasty for renovascular hypertension and preservation of renal function: long-term angiographic and clinical follow-up. Am J Roentgenol (1994) 162(Suppl 4):853–857.[Abstract/Free Full Text]
  17. Rivolta R, Bazzi C, Stradiotti P, Paparella M. Stenting of renal artery stenosis: is it beneficial in chronic renal failure? J Nephrol (2005) 18(Suppl 6):749–754.[Web of Science][Medline]
  18. Available at: ASTRAL- Angioplasty and STent for Renal Artery Lesions: www.astral.bham.ac.uk.
  19. Murphy T, Cooper C, Dworkin L, et al. The Cardiovascular Outcomes with Renal Atherosclerotic Lesions (CORAL) study: rationale and methods. J Vasc Interv Radiol (2005) 16(Suppl 10):1295–1300.[Web of Science][Medline]
Received for publication: 3. 7.06
Accepted in revised form: 14. 2.07


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