CV- nephro combined conference 2012.06.06

1. CV-nephro combined conference2012.06.06 報告者：fellow 1 陳筱惠 指導醫師：陳冠興醫師 Commented by CV1 張其任醫師

2. Patient Profile • Name: 張O嗣 • Sex: female • Age: 90-year-old • Chart number: 487733 • Date of admission: 2011/11/18

3. Chief Complaint • Persistent dizziness for 1 day

4. Present Illness • Underlying diseases: chronic kidney disease (stage 4), congestive heart failure, and atrial fibrillation • Dizziness with bradycardia episode at home (HR around 40bpm) • Associated S/S: no palpitation, chest pain, cold sweating, or consciousness disturbance • At ER: clear consiousness, af SVR

5. Past History • Hypertension (BP when OPD follow-up: 180~/70~mmHg) • Heart failure, LVEF:68%, HCVD related, atrial fibrillation rhythm • Chronic kidney disease, stage 4, eGFR: 29.4ml/min, 2011/04/24 crea: 1.64mg/dl • Obstrutive sleep apnea syndrome with restrictive lung • Asthma history • Other significant systemic diseases: denied

6. Current medicine • Doxazosin 4mg 1# bid • Isosorbide-5-mononitrate cr 60mg 1# qd • Furosemide 40ng 0.5# qd • Aliskiren 150mg 1# qd 2011/06/28~ • Exforge (Amlodipine 5mg + Valsartan 80mg) 1# bid 2011/11/15~ • Micardis Plus (Telmisartan 40mg + HCTZ 12.5mg) 1# qd 2011/10/18~2011/11/15 • Telmisartan 40mg

7. Personal History • Allergy: no known allergy • Alcohol: denied; betel-nut: denied; cigarette: denied • Over-the-counter medication or chinese herb: nil

8. Family History • No family history of malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases

9. Physical Examination • Vital signs: blood pressure: 135/58mmHg; temperature: 36.5‘C; pulse rate: 44/min; respiratory rate: 18/min • General appearance: acute ill looking • Eye: conjunctiva: pale, sclera: no icteric • Neck: supple, no lymphadenopathy or jugular vein engorgement • Chest: symmetric expansion breathing sound: bilateral clear heart sound: irregular heart beats, no S3 or S4, no murmurs • Abdomen: soft, flat, no tenderness, muscle guarding, or rebounding liver/spleen: impalpable bowel sound: normoactive • Extremities: no lower limb pitting edema • Skin: intact, no rash

10. Laboratory data – 2011/11/18

11. Impressions • Atrial fibrillation with slow ventricular rate, suspect hyperkalemia induced • Acute on chronic kidney disease, favor ARB drug effect, complicated with hyperkalemia and azotemia • Hypertension, poorly controlled • Heart failure, LVEF:68%, HCVD related, atrial fibrillation rhythm • Obstrutive sleep apnea syndrome with restrictive lung • Asthma history

12. Hospitalization course H/D

13. Kidney echo

14. Cortisol 14.1 Renin 1644 Aldosterone 328 TSH 0.77 Free T4 26.939

16. Renin 995

17. H/D

19. Hickman implantation

20. Renal angiography

21. Hold H/D

22. 1/17 remove hickman

23. Discussion – renal artery stenosis Renal Artery Stenosis: Optimizing Diagnosis and Treatment Progress in Cardiovascular Diseases 54 (2011) 29–35

24. 1st: atherosclerotic lesions, 90% of all renovascular lesions • Typically in older individuals • An equal prevalence in men and women • Predominantly at or near the origin of the renal artery and usually are associated with aortic disease • May present with hypertension or renal insufficiency

25. 2nd: fibromuscular dysplasia (FMD) • More often in young women • Usually associated with hypertension without renal insufficiency

26. A limited literature addresses the clinical factors that are predictive of finding atherosclerotic RAS and that may be useful in guiding appropriate screening.

28. Diagnostic methods • Doppler ultrasound • Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) • Conventional angiography Imaging For Renovascular Disease Seminars in Nephrology, Vol 31, No 3, May 2011, pp 272-282

29. Duplex ultrasonography: screening test • Sensitivity: 92.5% to 98%; specificity: 96% to 98% • Nontoxic • No exposure to ionizing radiation • Capable and reliable • Major limitation: dependence on technician skill for acquisition of adequate images; others: obesity, bowel gas, and recent food intake

32. Computed tomography angiography (CTA): • Sensitivity and specificity: > 95% • Multicenter Renal Artery Diagnostic Imaging Study in Hypertension (RADISH) study  SEN 64%, SPE 93% • Qualitative • Risk of contrast nephropathy

33. Magnetic resonance angiography (MRA): • Slightly lower sensitivities and specificities than CTA; RADISH study  SEN 62%, SPE 84% • To measure flow, renal perfusion, and renal function • Poorer spatial resolution, limited availability, patient tolerance, and the need for extended breath-holding • Nephrogenic sclerosing fibrosis associated with Gadolinium in patients with renal insufficiency

34. Duplex ultrasonography is inferior to MRA and CTA. Diagnostic tests for renal artery stenosis in patients suspected of having renovascular hypertension: a meta-analysis. Ann Intern Med 2001;135:401-411.

35. Captopril renography: • Poor screening test • Dependent on comparative imaging of the right and left kidneys • The incidence of bilateral RAS is approximately 30%. • May be useful when trying to determine the physiologic significance of a known intermediate stenosis

36. Invasive angiography: gold standard • Confirm the diagnosis based on prior noninvasive testing and with the intent to perform an intervention • The most commonly used methodology: intra-arterial digital subtraction angiography • Complications: related to the vascular access, placement of the guidecatheter into the renal artery, balloon and stent deployment, and contrast administration

37. Carbon dioxide (CO2) • Image quality is reduced. • May create greater uncertainty about lesion severity unless combined with judicious use of iodinated contrast

38. Treatment • Medical therapy • Revascularization: balloon angioplasty +- stenting or Surgical bypass or reconstruction • Goals: • Blood pressure control • Treatment of heart failure and/or pulmonary edema • Prevention of nephropathy

39. Medical therapy • Lifestyle interventions: • Dietary recommendations in atherosclerotic RAS: • Increased intake of fruits and vegetables, dietary calcium through low fat dairy products

40. Angiotensin-converting enzyme (ACE) inhibitors • Potential to induce acute hemodynamically mediated renal failure in patients with RAS • Lower cardiovascular event rates (10% vs 13%) and need for dialysis (1.5% vs 2.5%) • The cost of an increased risk of hospitalization for acute renal failure (1.2 vs 0.6%) • Selection bias: patients with better renal function and/or less severe disease are treated with these agents resulting in an apparent improvement of outcome

41. Other agents used to control the atherosclerotic process are important for the care of patients with atherosclerotic RAS. • Statins: decrease death, limit lesion progression, and promote restenosis-free survival • Platelet inhibitors: prevention of future cardiovascular events

42. Revascularization: • Balloon angioplasty +- stenting: • Lesion severity, renal function, the skill level of the operators, and complication rates • Surgical bypass or reconstruction: • Not benefit over angioplasty • High rates of adverse outcomes with surgery, including perioperative mortality of approximately 10%

43. When stenting is performed, there are a number of technical factors that should be considered as part of the procedure. • “No touch” technique for engaging a catheter into the renal artery  reduce the risk of atheroembolism • No embolic protection device is approved by the Food and Drug Administration for use in the renal artery. • Abciximab (a platelet glycoprotein IIbIIIa inhibitor) ??

44. A “cure” of hypertension with revascularization • < 10% in patients with atherosclerotic RAS • Approximately 50%in patients with FMD • Younger patients more likely to achieve this outcome. • Consistent and sustained blood pressure–lowering effect of revascularization

45. Considerable controversy exists regarding the use of revascularization of atherosclerotic RAS to treat or prevent the development of ischemic nephropathy. • Stent revascularization in patients with ischemic nephropathy and significant stenoses resulted in a slower rate of progression of nephropathy. • In a minority of patients, an actual improvement in renal function is seen with either stenting or surgical revascularization.

46. FMD: balloon angioplasty • In a minority of FMD cases, there will be concomitant aneurysms of the renal artery. • Atherosclerotic RAS • Stenting has proven superior to balloon angioplasty.

48. Thanks for your listening

49. Left kidney: 9.9 cm Right kidney: 7.7 cm

50. Right renal artery: occluded • Left renal artery: proximal 71% stenosis • Balloon dilatation procedures: 56% residual stenosis • Stenting: 5% residual stenosis