From the Division of Nephrology and Hypertension and the Departments of Radiology (J.F.G.), Mayo Clinic, Rochester, MN.
Cardiovascular Medicine (A.L.), Mayo Clinic, Rochester, MN.
Hypertension. 2020 Aug;76(2):497-505. doi: 10.1161/HYPERTENSIONAHA.120.15057. Epub 2020 Jun 8.
The significance of peristenotic collateral circulation (PCC) development around a stenotic renal artery is unknown. We tested the hypothesis that PCC is linked to loss of kidney function and recovery potential in patients with atherosclerotic renovascular disease (ARVD). Thirty-four patients with ARVD were assigned to medical-therapy with or without revascularization based on clinical indications. The PCC was visualized using multidetector computed tomography and defined relative to segmental arteries in patients with essential hypertension. PCC number before and 3 months after treatment was correlated with various renal parameters. Thirty-four stenotic kidneys from 30 patients were analyzed. PCC number correlated inversely with kidney volume. ARVD-stenotic kidneys with baseline PCC (collateral ARVD [C-ARVD], n=13) associated with elevated 24-hour urine protein and stenotic kidney vein level of tumor necrosis factor-α, lower single-kidney volume and blood flow, and greater hypoxia than in stenotic kidneys with no PCC (no collateral ARVD [NC-ARVD], n=17). Revascularization (but not medical-therapy alone) improved stenotic kidney function and reduced inflammation in both NC-ARVD and C-ARVD. In C-ARVD, revascularization also increased stenotic kidney volume, blood flow, and oxygenation to levels comparable to NC-ARVD, and induced PCC regression. However, revascularization improved systolic blood pressure, plasma renin activity, and filtration fraction only in NC-ARVD. Therefore, patients with C-ARVD have greater kidney dysfunction, atrophy, hypoxia, and inflammation compared with patients with NC-ARVD, suggesting that PCC does not effectively protect the stenotic kidney in ARVD. Renal artery revascularization improved in C-ARVD stenotic kidney function, but not hypertension or renin-angiotensin system activation. These observations may help direct management of patients with ARVD.
肾动脉狭窄周围的吻合侧支循环（PCC）的发展意义尚不清楚。我们检验了这样一个假说，即 PCC 与动脉粥样硬化性肾血管疾病（ARVD）患者的肾功能丧失和恢复潜力有关。根据临床指征，34 名 ARVD 患者被分为药物治疗组和血管重建组。使用多层螺旋 CT 观察 PCC，并在原发性高血压患者中相对于节段性动脉定义 PCC。治疗前后 3 个月的 PCC 数量与各种肾脏参数相关。分析了 30 名患者的 34 个狭窄肾脏。PCC 数量与肾脏体积呈反比。基线 PCC 的 ARVD 狭窄肾脏（伴侧支 ARVD [C-ARVD]，n=13）与 24 小时尿蛋白升高、狭窄肾静脉肿瘤坏死因子-α水平升高、单个肾脏体积和血流量降低以及缺氧程度较高有关，与无 PCC 的狭窄肾脏（无伴侧支 ARVD [NC-ARVD]，n=17）相比。血管重建（而非单纯药物治疗）改善了 NC-ARVD 和 C-ARVD 的狭窄肾脏功能，并降低了炎症反应。在 C-ARVD 中，血管重建还增加了狭窄肾脏的体积、血流和氧合作用，使其达到与 NC-ARVD 相当的水平，并诱导 PCC 消退。然而，血管重建仅在 NC-ARVD 中改善了收缩压、血浆肾素活性和滤过分数。因此，与 NC-ARVD 患者相比，C-ARVD 患者的肾功能障碍、萎缩、缺氧和炎症更为严重，这表明 PCC 并不能有效地保护 ARVD 中的狭窄肾脏。肾动脉血管重建改善了 C-ARVD 狭窄肾脏的功能，但不能改善高血压或肾素-血管紧张素系统的激活。这些观察结果可能有助于指导 ARVD 患者的管理。
