Textor S C, Wilcox C S
Divisions of Hypertension and Nephrology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA.
Annu Rev Med. 2001;52:421-42. doi: 10.1146/annurev.med.52.1.421.
Chronic azotemic renovascular disease is common in patients with atherosclerosis. Its prevalence appears to be increasing in the aging population. How often it is the primary cause of end-stage renal disease (ESRD) is not yet certain. Some studies suggest that 10%-40% of elderly hypertensive patients with newly documented ESRD and no demonstrable primary renal disease have significant renal artery stenosis (RAS). Atherosclerotic vascular occlusive disease of the renal arteries does progress, but current rates of progression and occlusion are lower than those reported a decade ago. Methods of identifying patients whose renal function is at true risk from vascular occlusive disease and determining who will benefit from intervention remain elusive. The presence of RAS in an azotemic patient can be assessed with noninvasive and risk-free radiologic techniques, including Duplex doppler velicometry and magnetic resonance angiography. Functional tests that predict the change in renal function after revascularization are not yet available. However, a renal length of greater than 7.5 cm in the absence of renal cysts and a short history of renal functional deterioration indicate a good prognosis. Patients with recent deterioration in renal function, those with bilateral renal artery stenosis or stenosis to a single functioning kidney, those with flash pulmonary edema, advanced chronic renal failure, or ESRD (who have much to gain), those with reversible azotemia during angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor antagonist (ARB) therapy, and those whose conditions cannot be managed medically should be considered for revascularization. Results from recent controlled clinical trials of the response to percutaneous transluminal renal artery angioplasty (PTRA) and stenting indicate that improvement in blood pressure control or renal function is not a predictable outcome of renal revascularization. In azotemic groups, 25%-30% of patients achieve important recovery of renal function. Thus, significant progress has been made recently in determining whether RAS is a frequent, treatable cause of renal failure. The decision to recommend revascularization remains a difficult balance between the risks and expense of the procedure and the undoubted benefits that accrue if renal function is successfully stabilized.
慢性氮质血症性肾血管疾病在动脉粥样硬化患者中很常见。在老龄化人群中，其患病率似乎在上升。它作为终末期肾病（ESRD）的主要病因的频率尚不确定。一些研究表明，10% - 40%新诊断为ESRD且无明显原发性肾病的老年高血压患者存在显著的肾动脉狭窄（RAS）。肾动脉的动脉粥样硬化性血管闭塞性疾病确实会进展，但目前的进展和闭塞率低于十年前报道的水平。识别肾功能真正因血管闭塞性疾病而处于风险中的患者以及确定谁将从干预中获益的方法仍然难以捉摸。氮质血症患者中RAS的存在可以通过无创且无风险的放射学技术进行评估，包括双功多普勒测速法和磁共振血管造影。目前尚无预测血管重建术后肾功能变化的功能测试。然而，在没有肾囊肿且肾功能恶化病史较短的情况下，肾长度大于7.5 cm表明预后良好。肾功能近期恶化的患者、双侧肾动脉狭窄或单肾功能性肾动脉狭窄的患者、有急性肺水肿的患者、晚期慢性肾衰竭或ESRD（获益较大）的患者、在血管紧张素转换酶抑制剂（ACEI）或血管紧张素受体拮抗剂（ARB）治疗期间有可逆性氮质血症的患者，以及那些病情无法通过药物治疗控制的患者，应考虑进行血管重建。近期关于经皮腔内肾动脉血管成形术（PTRA）和支架置入术反应的对照临床试验结果表明，血压控制或肾功能改善并非肾血管重建可预测的结果。在氮质血症组中，25% - 30%的患者肾功能有显著恢复。因此，最近在确定RAS是否是肾衰竭的常见且可治疗病因方面取得了重大进展。推荐进行血管重建的决定仍然是在该手术的风险和费用与肾功能成功稳定后无疑会带来的益处之间艰难权衡。
