FRINK Linked Data Fragments server

Matches in SemOpenAlex for { <https://semopenalex.org/work/W2614131027> ?p ?o ?g. }

• W2614131027 endingPage "163" @default.
• W2614131027 startingPage "160" @default.
• W2614131027 abstract "Commentary on Raman G, Adam GP, Halladay CW, Langberg VN, Azodo IA, Balk EM. Comparative effectiveness of management strategies for renal artery stenosis: an updated systematic review. Ann Intern Med. 2016;165(9):635-664. Commentary on Raman G, Adam GP, Halladay CW, Langberg VN, Azodo IA, Balk EM. Comparative effectiveness of management strategies for renal artery stenosis: an updated systematic review. Ann Intern Med. 2016;165(9):635-664. Occlusive renovascular disease presents a vexing challenge. Hypertension induced by renal artery stenosis is among the most widely studied and well-characterized causes of secondary hypertension. When arterial occlusion reaches critical levels, renal blood flow decreases and kidney function eventually deteriorates. It seems intuitive that restoring vessel patency and blood flow should provide clinical benefits both for relieving hypertension and preserving kidney function. This principle was widely accepted in the days of renovascular surgery (mainly in the 1970s) and after wider application of endovascular angioplasty and stenting (in the 1990s).1Textor S.C. Misra S. Oderich G. Percutaneous revascularization for ischemic nephropathy: the past, present and future.Kidney Int. 2013; 83: 28-40Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar The value of searching for surgically curable hypertension and salvageable ischemic kidneys seemed self-evident. Despite this history, management of the most common renovascular disease, atherosclerotic renal artery stenosis, has undergone dramatic shifts and triggered substantial controversy. Advances in antihypertensive drug therapy, including blockade of the renin-angiotensin system, make achieving goal blood pressures in renovascular hypertension with tolerable inexpensive regimens possible for most patients. Because atherosclerotic renal artery stenosis is associated with advancing age and multiple comorbid conditions, many patients with atherosclerotic renal artery stenosis experience unrelated disease events and now are commonly managed without revascularization. Whether this approach serves individual patients well in the long run remains controversial and has prompted several prospective randomized trials. Despite negative or ambiguous outcomes from these trials, numerous observational case series and registry data repeatedly demonstrate that some patients experience reversible kidney failure, refractory hypertension, and circulatory overload associated with atherosclerotic renal artery stenosis that can be reversed with effective revascularization. The question of how to integrate and interpret the body of data available in this field is challenging for clinicians in general and for nephrologists in particular. The article by Raman et al2Raman G. Adam G.P. Halladay C.W. Langberg V.N. Azodo I.A. Balk E.M. Comparative effectiveness of management strategies for renal artery stenosis: an updated systematic review.Ann Intern Med. 2016; 165: 635-664Crossref PubMed Scopus (47) Google Scholar was commissioned through the Agency for Healthcare Research and Quality (AHRQ) and presents results of a systematic review of published reports regarding the role of renal revascularization as compared to medical therapy only for patients with atherosclerotic renal arterial stenosis. This project sought to integrate more recent prospective randomized trials (specifically ASTRAL [Angioplasty and Stenting for Renal Artery Lesions]3Wheatley K. Ives N. Gray R. et al.The ASTRAL InvestigatorsRevascularization versus medical therapy for renal-artery stenosis.N Engl J Med. 2009; 361: 1953-1962Crossref PubMed Scopus (939) Google Scholar and CORAL [Cardiovascular Outcomes in Renal Atherosclerotic Lesions]4Cooper C.J. Murphy T.P. Cutlip D.E. et al.Stenting and medical therapy for atherosclerotic renal-artery stenosis.N Engl J Med. 2014; 370: 13-22Crossref PubMed Scopus (649) Google Scholar) with previous studies the same group had summarized in 2007. It also included nonrandomized clinical trials and case reports published during the same intervals. Hence, it presents a systematic review of published literature between 1993 and 2015. More than 1,560 citations were obtained from multiple databases, of which 189 were reviewed, in addition to 54 references from the initial report from 2007. These included 15 reports specifically comparing outcomes of medical therapy as compared to percutaneous transluminal angioplasty with stenting. Thirty-nine reports focused on adverse outcomes; 28 focused on outcome predictors, subgroup, or cotreatment analyses; and 20 focused on specific high-risk patient outcomes. Total enrolled patients in prospective randomized controlled trials (RCTs) were 2,178 (n = 7 studies). Data from n = 8 additional nonrandomized controlled studies included 1,828 patients. Importantly, decompensation (generally designated as episodes of pulmonary edema and/or rapidly progressive kidney failure) was an exclusion criterion in the prospective RCTs. Four other studies included patients with episodes of flash pulmonary edema or rapidly progressive hypertension and progressive kidney failure. Due to substantial clinical heterogeneity, no combination of data for meta-analysis was undertaken. All studies reviewed were evaluated using the risk-of-bias tools of Cochrane analysis and were examined for study, participant, and clinical atherosclerotic renal artery stenosis characteristics, as well as analytical design. The reviewers concluded that most studies were underpowered to examine mortality and other major outcomes over the time frames reported. As a result, many of the end points were considered to have low strength of evidence and identified no difference regarding mortality, progression to end-stage renal disease, or rates of cardiovascular disease events (definitions of these varied widely across different studies). Similarly, they concluded with low strength of evidence that some patients experience improved kidney function with renal revascularization and that blood pressure control was not different between those treated with medication primarily versus percutaneous transluminal angioplasty with stenting. Remarkably, adverse events related to revascularization procedures were uncommon. (Adverse effects related to medical therapy alone were not reported for the large majority of reports). Procedure-related deaths were rare (0.5% over 3 RCTs; none in CORAL, the largest trial). Adverse events such as pseudo-aneurysm, distal embolization, and acute kidney injury were also infrequent in recent series, averaging 3.2% overall. Analysis of participant demographic features failed to identify predictors of benefit consistently, including ethnicity, pre-existing diabetes, or bilateral disease. Most trials included patients defined simply by the presence of atherosclerotic renal artery stenosis and moderate clinical manifestations, such as hypertension or stage 3 chronic kidney disease. By contrast, observational series and case reports targeting decompensated or rapidly changing clinical syndromes identified mortality and clinical benefits for such patients. These reports underscore the limited generalizability of the prospective RCTs. The authors conclude from these data that “overall, the evidence does not support a benefit with percutaneous transluminal angioplasty with stenting over medical therapy alone in most patients with ARAS [atherosclerotic renal artery stenosis].”2Raman G. Adam G.P. Halladay C.W. Langberg V.N. Azodo I.A. Balk E.M. Comparative effectiveness of management strategies for renal artery stenosis: an updated systematic review.Ann Intern Med. 2016; 165: 635-664Crossref PubMed Scopus (47) Google Scholar They acknowledge that high-risk patients, namely patients who have worse kidney function or higher blood pressure (both variably defined) or flash pulmonary edema, may be more likely to experience improved kidney function and blood pressure after percutaneous transluminal angioplasty with stenting. This report summarizes the published experience with percutaneous transluminal angioplasty with stenting in atherosclerotic renal artery stenosis in a more systematic fashion than the individual studies and most clinical reviews. It offers the benefit of experienced study analysis from the perspective of the AHRQ, without absolutely excluding the information available from observational and clinical reports. Several features merit particular emphasis. First, despite the efforts to enlarge prospective RCTs, individual reports and combined series remain underpowered to detect moderate clinical benefits regarding mortality and major cardiovascular events. Hence, the authors’ conclusion that there is no benefit to renal revascularization must be tempered with the caveat of the low strength of evidence. Second, multiple observational series and case reports underscore major clinical and potential mortality benefits associated with renal revascularization in high-risk subsets. Importantly, these subsets are defined by clinical syndromes (eg, flash pulmonary edema) that are not evidently related to specific characteristics of the vascular stenosis itself, for example, the severity of occlusion or whether the vascular lesions are unilateral or bilateral. Third, reported complications associated with percutaneous transluminal angioplasty with stenting in the recent series are appreciably lower than in many earlier reports. Previous studies of targeted renal artery stent procedures report significant clinical events averaging 9% to 15% during the early postprocedure period that may increase to as high as 20% if followed up longer.5Rocha-Singh K. Jaff M.R. Rosenfield K. Aspire-2 Trial I. Evaluation of the safety and effectiveness of renal artery stenting after unsuccessful balloon angioplasty: the ASPIRE-2 study.J Am Coll Cardiol. 2005; 46: 776-783Crossref PubMed Scopus (157) Google Scholar Whether these reports truly reflect improved techniques and interventional expertise or patient selection cannot be fully determined. Nonetheless, these studies suggest that percutaneous transluminal angioplasty with stenting in experienced centers using more recent low-profile systems can restore kidney blood flow at low risk. At face value, the data presented in this systematic review generally support the inclination to delay renal artery revascularization in the management of patients with renovascular hypertension. Without a doubt, results of these trials have reduced the frequency of renal revascularization procedures in the United States and Europe. It may be argued that many previously unwarranted referrals for stenting procedures are less likely to occur. Despite these observations, professional consensus groups argue that a subset of high-risk patients with atherosclerotic renal artery stenosis may benefit from percutaneous transluminal angioplasty with stenting. The American Heart Association/American College of Cardiology guidelines from 2005 provide a class I recommendation for percutaneous transluminal angioplasty with stenting for high-risk patients with hemodynamically significant atherosclerotic renal artery stenosis and recurrent unexplained flash pulmonary edema.6Hirsch A.T. Haskal Z.J. Hertzer N.R. et al.ACC/AHA guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Associations for Vascular Surgery, Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task force on Practice Guidelines.J Vasc Interv Radiol. 2006; 17: 1383-1397Abstract Full Text Full Text PDF PubMed Scopus (382) Google Scholar This general approach has been confirmed and restated in recent consensus documents from multiple cardiovascular and interventional groups.7Rooke T.W. Hirsch A.T. Misra S. et al.2011 ACCF/AHA focused update of the guideline for the management of patients with peripheral artery disease.J Am Coll Cardiol. 2011; 58: 2020-2045Crossref PubMed Google Scholar, 8Parikh S.A. Shishehbor M.H. Gray B.H. et al.SCAI expert consensus statement for renal artery stenting appropriate use.Cathet Cardiovasc Interv. 2014; 84: 1163-1171Crossref PubMed Scopus (78) Google Scholar These recommendations take into consideration that some patients treated with optimal medical therapy nonetheless develop episodes of acute decompensation. Recent reviews of treatment-resistant hypertension also provide guidelines stating that percutaneous transluminal angioplasty with stenting should be considered for resistant or accelerated hypertension in patients with hemodynamically significant atherosclerotic renal artery stenosis and/or intolerance to antihypertensive medication.9White W.B. Turner J.R. Sica D.A. et al.Detection, evaluation, and treatment of severe and resistant hypertension: proceedings from an American Society of Hypertension Interactive forum held in Bethesda, MD, U.S.A., October 10th 2013.J Am Soc Hypertens. 2014; 8: 743-757Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 10Braam B. Taler S.J. Rahman M. et al.Recognition and management of resistant hypertension.Clin J Am Soc Nephrol. 2017; 12: 524-535Crossref PubMed Scopus (41) Google Scholar A recent subset analysis of more than 300 patients from CORAL with low levels of proteinuria identified a significant mortality benefit and reduction in cardiovascular event rate in patients with stents.11Murphy T.P. Cooper C.J. Pencina K.M. et al.Relationship of albuminuria and renal artery stent outcomes: results from the CORAL randomized clinical trial (Cardiovascular Outcomes With Renal Artery Lesions).Hypertension. 2016; 68: 1145-1152Crossref PubMed Scopus (43) Google Scholar Importantly, patients with atherosclerotic renal artery stenosis presenting with rapidly declining kidney function with bilateral atherosclerotic renal artery stenosis or stenosis to a solitary functioning kidney should be considered for revascularization to preserve kidney function.12Textor S.C. McKusick M.M. Renal artery stenosis: if and when to intervene.Curr Opin Nephrol Hypertens. 2016; 25: 144-151Crossref PubMed Scopus (19) Google Scholar Nephrologists need to recognize these major consequences of atherosclerotic renal artery stenosis not addressed in the RCTs: progressive deterioration of kidney function, uncontrolled hypertension, and flash pulmonary edema. Rather than pursue a single approach to patients with atherosclerotic renal artery stenosis, particular clinical conditions and changes over time need to be evaluated for each patient. Some nuances and limitations in this field extend beyond those evident in this systematic review. Serum creatinine as a marker of kidney function in atherosclerotic renal artery stenosis is flawed due to the opposing compensatory hemodynamics in the stenosed and contralateral kidney.13Herrmann S.M. Saad A. Eirin A. et al.Differences in GFR and tissue oxygenation, and interactions between stenotic and contralateral kidneys in unilateral atherosclerotic renovascular disease.Clin J Am Soc Nephrol. 2016; 11: 458-469Crossref PubMed Scopus (22) Google Scholar Accordingly, it is sometimes difficult to gauge the effect of both progressive disease and restoring blood flow on kidney function simply based on peripheral blood values alone. Timing of vascular intervention is another critical question. At some point, renal revascularization accomplishes little if the kidney structure has been irreversibly damaged. Long-term reductions in renal blood flow associated with tissue hypoxia in an atherosclerotic milieu lead to vascular rarefaction, activation of inflammatory injury, and fibrosis.14Textor S.C. Lerman L.O. Paradigm shifts in atherosclerotic renovascular disease: where are we now?.J Am Soc Nephrol. 2015; 26: 2074-2080Crossref PubMed Scopus (51) Google Scholar These are the dangers of waiting too long to restore blood flow to a critical organ. An understated corollary of depending on medical therapy primarily is the obligation to follow up individual patients for disease progression. Partly as a result of negative trials, we are encountering more patients who are referred after passing the point at which revascularization may be of benefit. For the practicing nephrologist, it is important not to miss the forest for the trees. This includes not overlooking the patient who may benefit from renal artery revascularization. Many patients may do well with medical therapy alone for many years. Nonetheless, indications for renal artery revascularization still exist, lest we forget the individual patient in the midst of meta-analyses. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute for Diabetes, Digestive and Kidney Diseases (NIDDK) or the National Institutes of Health (NIH). Support: This work was supported by grant R01 DK100081 from the NIDDK and NIH/National Center for Research Resources, Clinical and Translational Science Awards grant UL1 RR024150. Financial Disclosures: Dr Textor participates as a section editor for UpToDate and on the Data Safety Monitoring Board for Sentien Therapeutics. Dr Herrmann declares that she has no relevant financial interests. Peer Review: Evaluated by an Associate Editor and Deputy Editor Berns." @default.
• W2614131027 created "2017-05-26" @default.
• W2614131027 creator A5008724119 @default.
• W2614131027 creator A5079447750 @default.
• W2614131027 date "2017-08-01" @default.
• W2614131027 modified "2023-09-27" @default.
• W2614131027 title "Evidence and Renovascular Disease: Trials and Mistrials?" @default.
• W2614131027 cites W1560486856 @default.
• W2614131027 cites W1991906068 @default.
• W2614131027 cites W2029208313 @default.
• W2614131027 cites W2096538171 @default.
• W2614131027 cites W2130844583 @default.
• W2614131027 cites W2139861640 @default.
• W2614131027 cites W2141640685 @default.
• W2614131027 cites W2148367988 @default.
• W2614131027 cites W2163951953 @default.
• W2614131027 cites W2295755877 @default.
• W2614131027 cites W2306889839 @default.
• W2614131027 cites W2473372812 @default.
• W2614131027 cites W2522461160 @default.
• W2614131027 cites W2559703283 @default.
• W2614131027 cites W4233748100 @default.
• W2614131027 doi "https://doi.org/10.1053/j.ajkd.2017.04.013" @default.
• W2614131027 hasPubMedCentralId "https://www.ncbi.nlm.nih.gov/pmc/articles/5848211" @default.
• W2614131027 hasPubMedId "https://pubmed.ncbi.nlm.nih.gov/28535904" @default.
• W2614131027 hasPublicationYear "2017" @default.
• W2614131027 type Work @default.
• W2614131027 sameAs 2614131027 @default.
• W2614131027 citedByCount "5" @default.
• W2614131027 countsByYear W26141310272018 @default.
• W2614131027 countsByYear W26141310272019 @default.
• W2614131027 countsByYear W26141310272021 @default.
• W2614131027 crossrefType "journal-article" @default.
• W2614131027 hasAuthorship W2614131027A5008724119 @default.
• W2614131027 hasAuthorship W2614131027A5079447750 @default.
• W2614131027 hasBestOaLocation W26141310271 @default.
• W2614131027 hasConcept C126322002 @default.
• W2614131027 hasConcept C17744445 @default.
• W2614131027 hasConcept C199539241 @default.
• W2614131027 hasConcept C2779473830 @default.
• W2614131027 hasConcept C2780091579 @default.
• W2614131027 hasConcept C2781243531 @default.
• W2614131027 hasConcept C71924100 @default.
• W2614131027 hasConceptScore W2614131027C126322002 @default.
• W2614131027 hasConceptScore W2614131027C17744445 @default.
• W2614131027 hasConceptScore W2614131027C199539241 @default.
• W2614131027 hasConceptScore W2614131027C2779473830 @default.
• W2614131027 hasConceptScore W2614131027C2780091579 @default.
• W2614131027 hasConceptScore W2614131027C2781243531 @default.
• W2614131027 hasConceptScore W2614131027C71924100 @default.
• W2614131027 hasIssue "2" @default.
• W2614131027 hasLocation W26141310271 @default.
• W2614131027 hasLocation W26141310272 @default.
• W2614131027 hasLocation W26141310273 @default.
• W2614131027 hasLocation W26141310274 @default.
• W2614131027 hasOpenAccess W2614131027 @default.
• W2614131027 hasPrimaryLocation W26141310271 @default.
• W2614131027 hasRelatedWork W1992464788 @default.
• W2614131027 hasRelatedWork W1995943322 @default.
• W2614131027 hasRelatedWork W2036049010 @default.
• W2614131027 hasRelatedWork W2053512341 @default.
• W2614131027 hasRelatedWork W2314115817 @default.
• W2614131027 hasRelatedWork W2412084115 @default.
• W2614131027 hasRelatedWork W2842091216 @default.
• W2614131027 hasRelatedWork W2899084033 @default.
• W2614131027 hasRelatedWork W4248458259 @default.
• W2614131027 hasRelatedWork W4251256154 @default.
• W2614131027 hasVolume "70" @default.
• W2614131027 isParatext "false" @default.
• W2614131027 isRetracted "false" @default.
• W2614131027 magId "2614131027" @default.
• W2614131027 workType "article" @default.