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Atherosclerotic renovascular disease and progressive renal failure
1University of Vermont College of Medicine, Burlington.
Insights
Atherosclerotic renovascular disease is common in older adults and progresses, potentially leading to end-stage renal disease. Early diagnosis and intervention, including surgery or angioplasty, may improve outcomes compared to dialysis.
Area of Science:
- Nephrology
- Cardiology
- Vascular Medicine
Background:
- Atherosclerotic renovascular disease is prevalent in individuals over 50, often associated with diffuse atherosclerotic vascular disease.
- Hypertension is an unreliable indicator, with nearly half of affected patients not experiencing elevated blood pressure.
Purpose of the Study:
- To assess the prevalence, progression, and impact of angiotensin-converting enzyme inhibition on atherosclerotic renovascular disease.
- To inform a rational approach for diagnosing and managing this condition.
Main Methods:
- Review of retrospective analyses and existing literature, including MEDLINE searches and author bibliographies.
- Data extraction from selected articles focusing on incidence, progression, treatment outcomes, and mortality rates.
- Tabular presentation, summation, and averaging of data from individual reports.
Main Results:
- The disease progresses and contributes to 5-15% of annual end-stage renal disease cases.
- Angiotensin-converting enzyme inhibition presents a balance of potential tissue damage and therapeutic benefits.
- Mortality is high (>50% over 3 years) once end-stage renal disease occurs, with surgery and angioplasty offering potential to preserve function and delay dialysis.
Conclusions:
- Consideration of diagnosis and intervention is crucial for high-risk patients with progressive renal insufficiency.
- Prospective trials are essential to establish definitive costs and benefits of various treatment strategies for renovascular disease and renal insufficiency.
Purpose:
To evaluate information on the prevalence and rate of progression of atherosclerotic renovascular disease and the effect of angiotensin-converting enzyme inhibition on this process, with the goal of developing a rational approach to the diagnosis and management of this disorder.
Data Sources:
Relevant articles were identified from the authors' files and from MEDLINE searches. Additional references were obtained from the bibliographies of identified articles.
Study Selection:
Virtually no controlled prospective studies have been reported. The articles presented are primarily retrospective analyses and include those that provide sufficient information about the incidence or progression of renovascular disease and about the outcome and mortality rate associated with various treatments, to allow evaluation.
Data Extraction:
For the outcomes of interest, data from individual reports are presented in tabular form, the results summed, and averages obtained.
Results:
Atherosclerotic renovascular disease, in many cases involving both renal arteries, is a common finding in patients older than 50 years, particularly those with diffuse atherosclerotic vascular disease. Hypertension is not a particularly sensitive indicator of this disease (almost one half are not hypertensive). The disease progresses and may account for 5% to 15% of all patients developing end-stage renal disease each year. Angiotensin-converting enzyme inhibition may damage ischemic renal tissue, but this is counterbalanced by beneficial effects of this therapy. Once end-stage renal disease is present, mortality rates are high despite dialysis support (> 50% over 3 years). Both surgery and angioplasty can preserve or improve renal function and may delay or prevent the need for dialysis therapy. These invasive procedures may have lower rates of morbidity and mortality than the so-called "conservative" approach of dialysis therapy when renal failure develops.
Conclusions:
Given available information, diagnosis and intervention should be considered seriously in patients at high risk for renovascular disease who have clearly progressing renal insufficiency. Prospective trials are needed, however, to determine the costs and benefits of each approach to treatment in all patients with renovascular disease and renal insufficiency.