肾动脉狭窄的诊断和治疗的中国专家共识Chineseexpertconsensusonthe

1、肾动脉狭窄的诊断和治疗的中国专家共识(Chinese expertconsensus on the diagnosis and treatment of renal arterystenosis)Chinese expert consensus on the diagnosis and treatment of renal arterystenosis1. PrefaceRenal artery stenosis (RAS) is one of the most common causes ofsecondary hypertension. Takayasu arteritis, athero

2、sclerosis, andmuscle fiber dysplasia are the common causes of RAS. Prior to 1990s,Takayasu arteritis was the leading cause of renal artery stenosis inchina. But over the past ten years, atherosclerotic RAS has replacedTakayasu arteritis as the leading cause of RAS In recent years, theincidence of at

3、herosclerotic disease in China has been increasing.2. epidemiologyThe total diagnostic value of 65 years of age or older in the crowdRAS rate is about 6. 8%, higher in male than in female RAS has a higherincidence in high-risk groups (such as coronaryheart disease patientsand peripheral arterial dis

4、ease patients). Accept renal arteryangiography found that significant renal artery stenosis in undergoingcardiac catheterization (more than 50%) and the incidence rate is about11%18%.Atherosclerotic renal artery stenosis is a progressive disease.Renal artery occlusion is more common in patients with

5、 severe stenosisand those with diabetes or severe hypertension.Consequences of 3. RAS(1) renovascular hypertensionRenovascular hypertension is the second leading cause of secondaryhypertension. Although hypertension is a major clinical manifestationof RAS, the extent of anatomic renal artery stenosi

6、s is not linearlyrelated to hypertension.(2) end-stage renal disease (ESRD);A total of 683 patients with ESRD undergoing dialysis at the end ofthe last 20 years were studied, of whom 83 (12%) were diagnosed withRAS caused by ESRD However, according to the current data, we can notfully define the imp

7、act of RAS on ESRD There is no data to show howmany RAS patients eve nt ually need dialysis because of RAS (3) renal atrophy;Atrophy of the kidney is a direct consequence of RAS and is associatedwith the severity and progression of the disease The patient withprogressive renal failure is clinically

8、progressive The clinicalprognosis of patients with advanced RAS is poor (e.g., renal failure,reduced renal volume, and reduced survival)(4) recurrent pulmonary edema Patients with RAS may develop recurrentor recurrent pulmonary edema Patients with severe bilateral orunilateral RAS with hemodynamic s

9、ignificance may exhibit capacityoverload Patients with unilateral RAS may also experience increasedpulmonary edema due to an increase in left ventricular afterload dueto angiotensin mediated vasoconstrietion.the risk of cardiovascular eventsThe high risk of cardiovascular events in patients with RAS

10、 may be dueto a greater burden of systemic atherosclerosis. In patients withsevere RAS, coronary artery ischemia is induced by higher levels ofangiotensin II, which cause vasoconstriction of the surroundingarteries.(6) asymptomatic RASAsymptomatic asymptomatic RAS is also a clinical manifestation of

11、 RASin patients undergoing coronary angiography and peripheral angiography,and asymptomatic RAS. Compared with people without RAS, the prognosisof asymptomatic RAS patients is poor, and the prognosis is related tothe degree of RAS. A study found that the accidental discovery ofcardiac catheterizatio

12、n in asymptomatic and severe RAS (more than 75%)of the 4 year survival rate was 57%, and 89% patients with severe RAS.There is no research prospective, randomized controlled comparisongood to evaluate therapy in patients with symptoms of renal arterydisease (or related drugs) the relative risks and

13、benefits, so theeffect of these interventions remains controversia1.4.indicate the clinical condition of RASThe following situations may indicate a RAS(1) the following kinds of hypertension:A) hypertension before age 30 or severe hypertension after 55 yearsof age;increasesMalignant hypertension (b)

14、 of sudden worsening hypertension cancontrol the past);(c) resistant hypertension (which is still difficult to achieve whentarget blood pressure is used when combined with adequate amounts of3 antihypertensive drugs, including diuretics);(d) associated with malignant hypertension including acute ren

15、alfailure, acute decompensated congestive heart failure or new onset ofoptic nerve or other brain lesions and III IV retinopathy and acutehypertension target organ damage)(2) when the use of ACE I or ARB drugs occurs, the onse t of new onsetof hypoxemia or deterioration of renal function (elevated s

16、erumcreatinine is greater than 50%)(3) there is unexplained renal atrophy or bilateral kidney sizedifference greater than 1. 5cm(4) sudden unexplained pulmonary edema5. diagnostic toolsRecommend the use of duplex ultrasound, computed tomographyangiography (CTA), magnetic resonance angiography (MRA)

17、diagnosis oft hree noninvasive met hods of RAS images, when the clinical suspicionand noninvasive examination cannot draw reliable conclusions, can beused to diagnose RAS angiography. At present, indications fortranscatheter angiography are clinical manifestations of RAS, and nononinvasive examinati

18、on, or clinical symp to ms, and patie nt consent, and ready for peripheral artery or coronary angiography The accuracy of dual arterial duplex ultrasonography depends on thelevel of the operator and is affected by the size of the patient andwhether or not he has flatulence, but it is simple and conv

19、enient CTAis now more space efficient and easier to operate than MRA, but itsuse in patients with impaired renal function is limited by the needfor iodinated contrast agents For the MRA developer with gadoliniumin less kidney damage on the renal artery, peripheral vascular, renalparenchyma and renal

20、 function is to provide even better resuIts, butthe cost is higher, cannot imaging on the metal stent implantationpatients Compared with the transcatheter DSA, the sensitivity (above90%) and diagnostic value of MRA and CTA were not significantlydifferent in most vascular segments, and the consistenc

21、y between theobservers and the different morphological lesions was good Kato Pury renal scintigraphy, selective renal venous renin levels,plasma renin activity, and Kato Pury test, renin activity assay, arenot recommended for the diagnosis of RAS Kato Pury radionuclideimaging is applicable to the ma

22、jority of the population but itssignificance for smaller subgroups of renal vascular disease, in severeazotemia, bilateral renal artery stenosis or only unilateral renalfunctional RAS restricted its application value.6. drug therapyACE inhibitors and calcium antagonists are effective in controllingh

23、ypertension in RAS patients and delaying the progression of renaldisease. There is also evidence that diuretics and beta blockers canalso lower blood pressure in RAS patients to target levels But the benefits of drug therapy for advanced atherosclerotic renalartery disease include cessation of smoki

24、ng, treatment of dyslipidemiaand a combination therapy with aspirin. Angiotensin receptor blocker(ARB) can also reduce blood pressure in RAS patients, but the effectneeds to be confirmed by large-scale randomized trials Hypertensivepatients with RAS should be treated according to the guidelines forh

25、ypertension in china.Beta blocker is an effective drug in the treatment of hypertensioncaused by RAS ACE inhibitors and ARB may be effective in the treatmentof unilateral RAS induced hypertension. In patients with bilateral RASor solitary kidney RAS or decompensated congestive heart failure, theuse

26、of ACE inhibitors or ARB may lead to acute renal failure Transientchanges in renal function may be caused by many factors.Some patients may be a slight rise in the first two months, serumcreatinine ACE inhibitors or ARB (or 50%, abnormal reaction, renal ischemia At this point,the ACE inhibitor or AR

27、B should be deactivated, with the exception ofthe presence of RAS or other conditions. If the cause of renal ischemiais found and managed to be relieved, then the ACE inhibitor or ARB maybe used again, otherwise it should not be reused 7 revascularization(1) indications of interventional therapySuit

28、able for interventional therapy: a significant hemodynamicabnormalities, with the following RAS： Patients with malignanthypertension, hypertension, malignant hypertension, with unexplainedrenal hypertension and reduce intolerance of drug treatment ofhypertension; the progress of chronic kidneydiseas

29、e complicated withbilateral RAS or solitary kidney of RAS patients; patients with suddenpulmonary edema to have significant hemodynamic significance inpatients with RAS and RAS, with unexplained recurrent congestive heartfailure or unexplained; when combined with unstable angina, blood flowmechanics

30、 in patients with RAS.(2) surgical treatmentSurgical revascularization is suitable for patients withatherosclerotic RAS who need simultaneous renal aortic reconstruction(for the treatment of aortic aneurysms or severe primary iliac arteryocclusive disease) Patients with complex lesions extending int

31、osegmental arteries, and atherosclerotic RAS or FMD patients with hugeaneurysms, or multiple small renal artery involvement or main branchesof the main renal artery are involved 8.clinical evaluation of angioplasty(1) clinical eventsCardiovascular mortality in patients with renovascular hypertension

32、is higher than in patients with primary hypertension. The increasedrisk of hypertension is unknown It，s probably because ofatherosclerotic lesions all over the body, along with coronary andcerebrovascular diseases, not just hypertension. The improvement ofhypertension and renal function after renal

33、artery angioplasty can onlybe used as an alternative marker of cardiovascular events. To determinethe outcome of renal artery intervention, clinical events should beconsidered the gold standard. Clinical events such as patientmortality, cardiovascular death, and nonfatai cardiovascular eventsshould

34、be treated as the ultimate goal of treatment.(2) hypertensionEach time the blood pressure is measured, the antihypertensive drugsand dosages that the patient is taking must be recorded (3) evaluation of renal functionThere are many definitions of renal function benefits after renalartery stenting, a

35、nd most of the reports looked at changes in serumcreatinine as a parameter to evaluate success After treatment withcreatinine clearance (GFR) as a starting point, the defined prognosticindicators are failure and gainsHowever, it is important to recognizethat the intervention is not only manifested i

36、n changes in GFR absolutevalues, but also in patients with progressive GFR decline with sloweror slower renal function. In other words, evaluation in different timeperiods after the intervention with renal function, renal function andevaluate the therapeutic effect with the change trend of equallyef

37、fective and valuable, changing trend of decline in renal functionassessment before and after intervention. Since the measurement ofserum creatinine immediately after angioplasty is influenced bycontrast agents or perioperative dehydration, the assessment of earlyrenal function with creatinine should

38、 be performed more than 1 weeksafter intervention.After the discovery of RAS, it is necessary to perform sequential GFRassay before and after intervention and to observe the changes of renalfunction. Patients should have at least 5 times of valid GFR data atleast 3 months prior to randomization. Fol

39、low up data should be obtainedwithin the prescribed period of 1 weeks after treatment than in theobservation period, at least 3 months to record sufficient data toevaluate the therapeutic effect During the trial, additional GFR (orserum creatinine) should be added to the patient over a longer periodof time if the patiens renal function deteriorates. Lo