QJM Advance Access originally published online on March 28, 2008
QJM 2008 101(7):519-527; doi:10.1093/qjmed/hcn039
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Worsening renal failure in older chronic kidney disease patients with renal artery stenosis concurrently on renin angiotensin aldosterone system blockade: a prospective 50-month Mayo-Health-System clinic analysis *
From the 1College of Medicine, Mayo Clinic, Rochester, MN, 2Department of Nephrology, Midelfort Clinic, Mayo Health System, and 3NT Systems, Eau Claire, WI, USA
Address correspondence to M.A.C. Onuigbo, MD, MSc, FWACP, FASN. email: onuigbo.macaulay{at}mayo.edu
Received 4 October 2007 and in revised form 5 December 2007
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Abstract |
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Background: The current US chronic kidney disease (CKD)/end stage renal disease (ESRD) epidemic, coincident with the increasing application of renin angiotensin aldosterone system (RAAS) blockade, has raised concerns of iatrogenic renal failure. The US population is an ageing one, further raising the possibility of increasing renal artery stenosis (RAS) in our patients. Current literature regarding worsening renal failure in CKD patients with RAS is based almost wholly on retrospective studies, and therefore may be poorly understood.
Aim: To prospectively examine the syndrome of worsening renal failure in CKD patients with hemodynamically significant RAS concurrently on RAAS blockade.
Design: Prospective cohort study.
Methods: Between September 2002 and February 2005, CKD patients, concurrently on RAAS blockade, with RAS >70% by magnetic resonance angiography, who presented with accelerated azotemia (
25% increase in baseline serum creatinine) were consecutively enrolled. In addition to standard nephrology care, RAAS blockade was discontinued and renal percutaneous transluminal angioplasty (PTA)/stenting performed according to standard guidelines. Renal function as measured by MDRD-derived eGFR (estimated glomerular filtration rate) was monitored.
Results: Twenty-six Caucasian patients were enrolled—M:F = 10:16, mean age 75.3 years. Prior duration of RAAS blockade was 20.2 months. Known risk factors were absent in 15/26. Unilateral RAS with dual kidneys was common—19/26. Five patients, with higher baseline creatinine—2.1 ± 0.6 vs. 1.5 ± 0.4 mg/dl, P = 0.013, progressed to ESRD; 4/5 ESRD patients died after 6.3 months. Excluding the 5 with ESRD, and 2 lost to follow-up, in 19 patients, eGFR increased from 27.8 ± 9.5 to 39.7 ± 14.9 ml/min/1.73 m2 BSA (P = 0.001), 26.4 months after stopping RAAS blockade. In these same 19 patients, mean arterial blood pressure improved from 100 ± 9 to 92 ± 10 mmHg, with 8 patients requiring additional antihypertensive substitutions. Renal PTA/stenting further improved eGFR in 7/9 patients.
Conclusions: Contrary to previous retrospective reports, we observed that renal failure/ESRD in this older CKD patient population is common in patients with unilateral RAS lesions with dual kidneys; precipitating risk factors are often absent, and progression to ESRD with increased mortality is not infrequent. Older age, higher baseline creatinine (>2.0) and/or lower eGFR (<35) predicted ESRD. eGFR improved following discontinuation of RAAS blockade, generally. Furthermore, in selected patients, renal PTA and stent placement led to additional improvements in eGFR. Our observations call for further studies.
*This work is dedicated, first and foremost, to the memory of our dearly beloved and loving mother, mother-in-law and grand-mother, Mrs. Janet Nwofor, who passed on to the Lord in 2005. Second, this work is also dedicated to the memory of a pleasant unnamed 74-year-old white woman, with ESRD, who died suddenly at home, watching television, probably from a malignant cardiac arrhythmia, sometime in 2006.
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  M.A.C. Onuigbo Reno-prevention vs. reno-protection: a critical re-appraisal of the evidence-base from the large RAAS blockade trials after ontarget--a call for more circumspection QJM, January 5, 2009; (2009) hcn142v2. [Abstract] [Full Text] [PDF]
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