Marboeuf Philippe, Delsart Pascal, Hurt Christopher, Villers Arnaud, Hossein-Foucher Claude, Beregi Jean-Paul, Deklunder Ghislaine, Noel Christian, Mounier-Vehier Claire
Service de Médecine Vasculaire et HTA, CHRU LILLE, F-59000 Lille, France.
Presse Med. 2010 Apr;39(4):e67-76. doi: 10.1016/j.lpm.2009.07.020. Epub 2009 Oct 23.
In the absence of specific treatment, patients with renal vascular disease develop renal atrophy. This population frequently has hypertension refractory to medical treatment. The patients who may respond to revascularization or at the worst to a nephrectomy must be identified to optimize their therapeutic management.
We conducted an observational retrospective study of hypertensive patients with unilateral renal atrophy (renal height < 9 cm) followed at the Lille University Hospital Center from 1998 to 2006. Hypertension, renal clearance (by scintigraphy with MAG3), and hypersecretion of renin (segmental/selective venous renin samples) were studied. We subsequently classified the patients into 3 groups. Medical treatment was optimized for all.
The mean follow-up period was 1.3+/-0.2 years. Eight patients were treated medically (group 1). Endovascular revascularization was used to treat the subjects for which atrophic kidney function accounted for more than 10% of their total renal function and with stenosis of the renal artery (>70%) (group 2, n=19). Those with a small nonfunctional kidney (<10% of total renal function) and hypersecretion of renin (ratio>1.5 in relation to the contralateral kidney) underwent a nephrectomy (group 3, n=8). The reduction in systolic blood pressure (SBP) was 27 mm Hg and diastolic blood pressure (DBP) 14 mm Hg for the overall study population (p < 0.001), without any significant aggravation of renal function. In group 1, the reduction in blood pressure was lower, with medical treatment alone; SBP fell by 13 mm Hg and DBP by 4mm Hg (p=ns) ; this group had the lowest initial blood pressure. In group 2, revascularization made it possible to improve SBP by 26 mm Hg and DBP by 14 mm Hg (p < 0.01) without significant impairment of renal function. Group 3 showed the most spectacular improvement in blood pressure, with SBP dropping by 40 mm Hg and DBP by 19 mm Hg (p=0.016). But it was also in this group that we observed an aggravation in the rate of glomerular filtration with a nonsignificant reduction of 12.8 mL/min, nonetheless superior to that expected according to the preoperative scintigraphy.
The results of this work underline the importance of multidisciplinary management of patients with small ischemic kidneys. Preselection of patients in unstable clinical situations (refractory hypertension, progressive kidney failure, flash pulmonary edema) by isotopic and endocrinal renal evaluation provides a basis for deciding on treatment. The existence of a renin ratio >1.5 can identify the patients most likely to respond to nephrectomy. The reduction of renal function following nephrectomy must be considered in the discussion about treatment. The functional threshold initially defined at 10% may be lowered to 5%, to limit this postoperative reduction.
在缺乏特异性治疗的情况下，肾血管疾病患者会出现肾萎缩。这类患者常常患有药物治疗难以控制的高血压。必须识别出那些可能对血管重建术有反应或在最坏情况下对肾切除术有反应的患者，以优化其治疗管理。
我们对1998年至2006年在里尔大学医院中心随访的单侧肾萎缩（肾长径<9cm）高血压患者进行了一项观察性回顾性研究。研究了高血压、肾清除率（通过MAG3闪烁扫描）和肾素高分泌（节段性/选择性静脉肾素样本）情况。随后我们将患者分为3组。对所有患者的药物治疗进行了优化。
平均随访期为1.3±0.2年。8例患者接受药物治疗（第1组）。对于萎缩肾功能占其总肾功能10%以上且肾动脉狭窄（>70%）的患者，采用血管内血管重建术进行治疗（第2组，n = 19）。对于肾无功能且体积小（<总肾功能的10%）以及肾素高分泌（与对侧肾脏相比比值>1.5）的患者，进行了肾切除术（第3组，n = 8）。整个研究人群的收缩压（SBP）下降了27mmHg，舒张压（DBP）下降了14mmHg（p < 0.001），肾功能没有任何显著恶化。在第1组中，仅药物治疗时血压下降幅度较小；SBP下降了13mmHg，DBP下降了4mmHg（p =无统计学意义）；该组初始血压最低。在第2组中，血管重建术使SBP提高了26mmHg，DBP提高了14mmHg（p < 0.01），且肾功能没有显著损害。第3组血压改善最为显著，SBP下降了40mmHg，DBP下降了19mmHg（p = 0.016）。但也正是在这组中，我们观察到肾小球滤过率有所恶化，虽无显著降低，但降低了12.8mL/min，不过仍优于术前闪烁扫描预期的降低幅度。
这项工作的结果强调了对小缺血性肾脏患者进行多学科管理的重要性。通过同位素和内分泌肾脏评估对临床情况不稳定（难治性高血压、进行性肾衰竭、急性肺水肿）的患者进行预先筛选，为决定治疗方案提供了依据。肾素比值>1.5可识别出最可能对肾切除术有反应的患者。在讨论治疗方案时必须考虑肾切除术后肾功能的降低情况。最初定义为10% 的功能阈值可降至5%，以限制术后肾功能的降低。
