Dallas Veterans Affairs Medical Center, Dallas, TX, USA.
J Vasc Surg. 2011 Nov;54(5):1414-1421.e1; discussion 1420-1. doi: 10.1016/j.jvs.2011.04.042. Epub 2011 Jul 31.
To identify preoperative clinical features that predict a durable improvement in renal function with renal artery stenting (RAS).
Sixty-one patients with renal insufficiency (serum creatinine ≥ 1.5 mg/dL) underwent RAS for renal salvage. Patients were categorized as "responders" if estimated glomerular filtration rate (eGFR) at last follow-up was improved 20% or more over baseline. Patients with stable or worse renal function after RAS were labeled "non-responders." For the purpose of calculating changes in eGFR, patients on dialysis were represented by an eGFR of 10 ml/min/1.73 m(2). Renal volume was estimated as kidney length × width × depth/2.
The median age of the cohort was 66 years (interquartile range [IQR], 60-73 years). Median preoperative serum creatinine was 1.8 mg/dL (IQR, 1.6-2.3), and median estimated glomerular filtration rate (eGFR) was 34 mL/min/1.73 m(2) (IQR, 24-45). With stenting, 17 of 61 patients (27.9%) derived a durable improvement in renal function at a median follow-up of 24 months (IQR, 16-33 months). The largest proportion of stented patients (44.3%) had no improvement in renal function after stenting, while a subset (27.9%) experienced a decline in renal function. Responders enjoyed a 47% improvement in renal function from baseline, while non-responders had a 13% decrement in renal function (P < .0001). Responders had a higher baseline serum creatinine, lower eGFR, and a steeper decline in renal function prior to RAS, compared with non-responders. Kidney length, width, depth, and volume were not significantly different between responders and non-responders. Logistic regression analysis identified the rate of decline of renal function prior to stenting as the only independent preoperative predictor of improved renal function after RAS (odds ratio, 3.4; 95% confidence interval, 1.6 to 7.5; P = .0019). The rate of decline in eGFR per week was more than 20-fold greater for responders than non-responders (2.1% vs 0% decline in eGFR per week; P < .0001). No predictors of renal function deterioration after stenting were identified.
The current study found that a steep decline in preoperative renal function portends a higher likelihood of renal salvage from RAS among patients with renal insufficiency. Incorporating this finding into patient selection may improve outcomes for RAS.
确定预测经肾动脉支架置入术（RAS）后肾功能持久改善的术前临床特征。
61 例肾功能不全（血清肌酐≥1.5mg/dL）患者接受 RAS 以挽救肾功能。如果最后一次随访时估算肾小球滤过率（eGFR）比基线水平提高 20%或更多，则将患者归类为“有反应者”。RAS 后肾功能稳定或恶化的患者被标记为“无反应者”。为了计算 eGFR 的变化，接受透析的患者用 eGFR 为 10ml/min/1.73m2表示。肾体积估计为肾长×宽×深/2。
队列的中位年龄为 66 岁（四分位距[IQR]，60-73 岁）。术前中位血清肌酐为 1.8mg/dL（IQR，1.6-2.3），中位估算肾小球滤过率（eGFR）为 34ml/min/1.73m2（IQR，24-45）。在支架置入后，61 例患者中有 17 例（27.9%）在中位随访 24 个月（IQR，16-33 个月）时肾功能持久改善。最大比例的支架置入患者（44.3%）在支架置入后肾功能无改善，而部分患者（27.9%）肾功能下降。有反应者的肾功能较基线水平提高了 47%，而无反应者的肾功能下降了 13%（P<0.0001）。与无反应者相比，有反应者的基线血清肌酐更高，eGFR 更低，RAS 前肾功能下降更陡峭。有反应者和无反应者的肾长、宽、深和体积无显著差异。逻辑回归分析确定 RAS 前肾功能下降率是 RAS 后肾功能改善的唯一独立术前预测因素（比值比，3.4；95%置信区间，1.6 至 7.5；P=0.0019）。有反应者的 eGFR 每周下降速度比无反应者高 20 多倍（每周 eGFR 下降 2.1%与 0%；P<0.0001）。未发现支架置入后肾功能恶化的预测因素。
本研究发现，术前肾功能急剧下降预示着肾功能不全患者 RAS 后肾挽救的可能性更高。将这一发现纳入患者选择可能会改善 RAS 的结果。
