肾血管病的处理课件

1、Management of Renovascular Hypertension阜外心血管病医院心内科蒋雄京肾血管病的处理1Management of Renovascular Hy Interrelation among Renal Artery Stenosis, Hypertension, and Chronic Renal Failure 肾血管病的处理2 Interrelation among Renal Art Definition of Renal Artery StenosisRenal artery stenosis (RAS) is defined as narrowing

2、of the lumen of the renal artery. *angiographic diameter stenosis50%*translesional pressure gradient of 20 mm Hg peak systolic or 10 mm Hg mean The most common causes of RAS are atherosclerosis (80%) , aortoarteritis(15%), and fibromuscular dysplasia(50% 9.7Bilateral, %1.7IndicationSuspected CHDWang

3、 et al23014.8NRCHDShen et al28015.35.0Suspected CHDLiu et al14118.4NRSuspected CHDMean185111.8NR肾血管病的处理7Incidence of Renal Artery Sten肾血管病的处理8肾血管病的处理8Progressive Atherosclerosis, Renal Artery Stenosis, and Ischemic Nephropathy 肾血管病的处理9Progressive Atherosclerosis, Rthe clinical manifestations of ARVD

4、 肾血管病的处理10the clinical manifestations ofClinical features suggestive of renovascular hypertensionJNC-VI Onset of hypertension aged30 y;Abdominal bruit;Accelerated or resistant hypertension;Flash pulmonary edema with normal left ventricular function;Renal failure of uncertain cause;Coexisting, diffus

5、e atherosclerotic vascular diseaseAcute renal failure precipitate by antihypertensive therapy, particularly ACEI or AII receptor blockers; In the presence of these clinical clues the prevalence of RVH is 40%.肾血管病的处理11Clinical features suggestive oScreening for Renovascular Hypertension1 .Radionuclid

6、e renal fractional flow /GFR2. Plasma renin activity3. Captopril renoscitigraphy4. Color dopplor ultrasonography5. MR Angiography / CT Angiography肾血管病的处理12Screening for Renovascular HypMulti-slices CTA is most useful for RAS screening肾血管病的处理13Multi-slices CTA is most usefuSeverity of renal vascular

7、disease predicts mortality in patients undergoing coronary angiographyKidney International (2001) 60, 14901497肾血管病的处理14Severity of renal vascular dis肾血管病的处理15肾血管病的处理15Clinical Criteria for RevascularizationHypertension: accelerated hypertension; refractory hypertension; malignant hypertension; hyper

8、tension with a unilateral small kidney; or hypertension with intolerance to medication. Renal salvage: sudden unexplained worsening of renal function; impairment of renal function secondary to antihypertensive treatment, particularly with an angiotensin-converting enzyme inhibitor or angiotensin II

9、receptor blocker; or renal dysfunction not attributable to another cause. Cardiac disturbance syndromes: recurrent flash pulmonary edema out of proportion to any impairment of left ventricular function,or unstable angina in the setting of significant RAS.肾血管病的处理16Clinical Criteria for RevasculMedica

10、l Therapy control of blood pressure : ACE inhibitors or Angiotensin receptor blockers ?antiplatelet therapysmoking cessationaggressive control of hyperlipidemia and DM The best medical therapy for ARVD remains unclear. Medical therapy hardly prevents renal function worsen in patients with bilateral

11、RAS or RAS of single kidney. Chabova V, et al. Mayo Clin Proc 2000;75:437-444 Baboolal K Am J Kidney Dis 1998;31:971-977肾血管病的处理17Medical Therapy control of blo肾动脉支架置入 肾血管病的处理18肾动脉支架置入 肾血管病的处理18meta-analysis data demonstrating superiority of renal artery stent compared with balloon angioplasty for pr

12、ocedure success and restenosis rates肾血管病的处理19meta-analysis data demonstrati术前准备阿斯匹林0.10.3 QD, 氯吡格雷75mg QD ，2-3天;降压,血压控制在90%）肾血管病的处理27Case report -1女，60岁，发现高血压2年，最高肾血管病的处理28肾血管病的处理28 GFR 左（min/l） 右（ min/l ）术前 24.0 20.4术后（第3天) 21.3 34.6肾照相（99mTc-DTPA）肾血管病的处理29 GFR 左（mi术后随访拜新同30mg,Qd;阿托伐他丁10mg,Qn;阿斯匹林0

13、.1 ,Qd;氯吡格雷75mg,Qd,1个月术后2周 ：Bp120/82mmHg,Cr125.4umol/L,BUN7.39mmol/L术后6个月 ：Bp132/86mmHg,Cr115umol/L,BUN6.2 mmol/L术后12个月：Bp128/84mmHg,Cr118umol/L,BUN7.2 mmol/L术后18个月：Bp136/88mmHg,Cr128umol/L,BUN7.9 mmol/L肾血管病的处理30术后随访拜新同30mg,Qd;阿托伐他丁10mg,Qn;阿斯ARVD Randomized StudiesPTRA vs Medication肾血管病的处理31ARVD Ran

14、domized Studies肾血管病的肾动脉支架的临床结果文献汇总分析：肾功能： 1/3 提高 1/3 不变 1/3恶化高血压： 治愈 改善FMD 50 85% 85 - 100%ARAS 5 15% 50 70%TA 40 - 60% 75 - 90%肾血管病的处理32肾动脉支架的临床结果文献汇总分析： ASTRALAngioplasty and STent for Renal Artery LesionsUK MULTI-CENTRE TRIAL INATHEROSCLEROTIC RENOVASCULAR DISEASEPhilip A KalraLead Nephrologist f

15、or ASTRAL, Hope Hospital, Salford, UK,On behalf of the ASTRAL TMC and collaborators肾血管病的处理33ASTRALPhilip A Kalra肾血管病的处理33ASTRAL Trial: Design806403 Medical Rx 403 Stent Assigned308 Stent(76%)44 NotAttempted17 Failed34 NotKnown肾血管病的处理34ASTRAL Trial: Design806403 MedPrimary and secondary end points in

16、 ASTRALPrimary end point Secondary end points Blood pressure controlRenal events (such as acute renal failure, dialysis, transplant or nephrectomy)Serious vascular events (such as myocardial infarction, angina or stroke)MortalityRate of progression of renal dysfunction (using serum creatinine analys

17、ed by reciprocal creatinine plots over time)肾血管病的处理35Primary and secondary end poin Stent Med Rx p ValueAge 70 71 NSMale 63% 63% NSDiabetes 31% 29% NSCr 179 178 NSGFR 40 39 NSBilateral 50% 50% NSACE/ARB 47% 38% NSBaseline Characteristics肾血管病的处理36 Stent Med Rx ASTRAL: Lesion SeverityMean = 76% (Range

18、: 20% 100%)Site reported: no core labNo. of patientsStenosis(%)肾血管病的处理37ASTRAL: Lesion SeverityMean = ASTRAL: TreatmentRevascularization Strategies:Stenting 93% PTA alone 7%Post-stent residual stenosis 50%: 12%Complications: 7% Perforations: 4 (1%) Cholesterol Emboli 3 (1%) Death 180/110 mmHg或正规三联降压

19、药治疗血压140/90mmHg；(3)血肌酐7.0cm，并且残余的GFR10ml/min；(5)年龄30岁，性别不限。排除标准：(1)病情不稳定，无法耐受介入治疗；(2)造影剂过敏；(3)肾动脉病变的解剖条件不适合进行介入治疗 肾血管病的处理51资料与方法本研究病例入选标准：肾血管病的处理51结果-患者的基本临床特征 患者(n=238)的基线临床特征年龄(岁)3383(64.29.5)男性,例(%)178(74.8)糖尿病,例(%)62(26.1)高脂血症,例(%)136(57.1)吸烟(目前或曾经),例(%)141(59.2)合并其他外周血管疾病,例(%)105(44.1)术前蛋白尿,例(%

20、)20(8.4)脑卒中或短暂脑缺血发作史,例(%)45(18.9)冠心病,例(%)156(65.5)心肌梗死史,例(%)53(22.3)瓣膜性心脏病,例(%)12(5.0)严重慢性心衰(NYHA级),例(%)17(7.1)肾血管病的处理52结果-患者的基本临床特征 患者(n=238)的基线临床特征年结果-患者的基本临床特征患者(n=238)的基线临床特征(续) 高血压病史(月)1600(159.5143.9)收缩压(mmHg)161.622.2舒张压(mmHg)94.68.8服用降压药种类数(种)15(2.91.6)狭窄程度(%)60100(82.98.1)单侧肾动脉狭窄,例(%)172(72

21、.3)双侧肾动脉狭窄,例(%)66(27.7)开口和(或)近端狭窄,条(%)292(95.4)中远端狭窄,条(%)14(4.6)术前管腔直径(mm)02.45(1.00.5)血肌酐水平(umol/L)44.0263.92(108.942.3) 血肌酐133umol/L,例(%)202(84.9) 血肌酐133177umol/L,例(%)26(10.9) 血肌酐177umol/L,例(%)10(4.2)血尿素水平(mmol/L)2.923.8(7.53.3)肾血管病的处理53结果-患者的基本临床特征患者(n=238)的基线临床特征(续PTRAS的造影和支架结果及并发症 238例患者中2例的2条肾

22、动脉发生严重夹层，1例的1条分支血管被支架压闭，总的血运重建技术成功率99%(303/306)。PTRAS相关并发症总计5.5%(13/238).并发症转归股动脉穿刺点大血肿2例，出血1例均经输血和延长加压包扎后治愈股动脉穿刺点假性动脉瘤形成1例经外科手术修补后治愈急性肾功能不全3例(2例夹层)1例2周后恢复至术前水平，1例持续恶化，1例术后第6日心源性猝死1例的1条分支血管被支架压闭 肾功能未受影响 手术侧肾囊血肿伴血色素进行性下降2例考虑系肾动脉穿孔所致，经输血后好转，随访观测基本吸收脑卒中3例缺血性2例，1例无后遗症，1例有后遗症，出血性1例，术后第3日死亡肾血管病的处理54PTRAS的

23、造影和支架结果及并发症 238例患者中2例的2条结果-随访及失访情况 随访时间(月)61218243036424854606672应有人数(例)238225193159134112967563453726实际随访到的总人数(例)228219192158131111967463453726失访人数(例)1061131010000死亡人数(例)740101101000实际随访到的存活人数(例)22120818114611998826048302211 随访672(29.219.6)个月，共失访23例(9.7%)肾血管病的处理55结果-随访及失访情况 随访时间(月)612182430364PTRAS

24、对血压的影响临床判定的支架内再狭窄率3.0%(7/238)肾血管病的处理56PTRAS对血压的影响临床判定的支架内再狭窄率3.0%(7/PTRAS对肾功能的影响肾血管病的处理57PTRAS对肾功能的影响肾血管病的处理57PTRAS后血压和肾功能转归36例术前肾功能异常的患者，PTRS后肾功能改善21例(77.8%)无变化9例(25%) ，恶化3例(8.3%)(其中2例发展至肾衰竭尿毒症期，已行透析治疗)，失访2例(5.6%) ，死亡1例(2.7%)。 术后6、12个月时患者的血压和肾功能转归(例)观察时间例数血压肌酐治愈改善无效改善无变化恶化术后6个月221(100)3(1.4)184(83.

25、2)34(15.4)71(32.1)133(60.2)17(7.7)术后12个月208(100)5(2.4)176(84.6)27(13.0)65(31.3)122(58.7)21(10.0)肾血管病的处理58PTRAS后血压和肾功能转归36例术前肾功能异常的患者，PT本研究PTRAS后的无事件生存率Severity of renal vascular disease predicts mortality in patients undergoing CAGKidney International (2001) 60, 14901497肾血管病的处理59本研究PTRAS后的无事件生存率Seve

26、rity of rePTRAS后的心血管事件共发生心血管事件24例(10.1%)，另有其他原因死亡4例。 心血管事件例数肾脏事件5例(2.1%)急性心肌梗死4例(1.7%)脑卒中4例(1.7%)心脑血管死亡11例(4.6%)肾血管病的处理60PTRAS后的心血管事件共发生心血管事件24例(10.1%)随访期患者发生各种心血管事件的相关因素事件相关因素优势比(95%CI)P心脑血管死亡术后12个月高血压治愈或改善0.070(0.011-0.453)0.008术后12个月肾功能改善或稳定0.090(0.016-0.476)0.009总死亡术后12个月高血压治愈或改善0.002(0.000-0.15

27、1)0.005术后12个月肾功能改善或稳定0.013(0.000-0.785)0.038年龄1.640(1.071-2.513)0.023术前基线收缩压值1.067(1.002-1.137)0.044肾脏事件术后12个月肾功能改善或稳定0.009(0.000-0.524)0.025术前基线尿素氮值1.409(1.049-2.157)0.03所有心血管事件术后12个月高血压治愈或改善0.098(0.019-0.499)0.005术后12个月肾功能改善或稳定0.134(0.035-0.509)0.003术前基线收缩压值1.032(1.005-1.059)0.019肾血管病的处理61随访期患者发生各

28、种心血管事件的相关因素事件相关因素优势比Case 1: Bilateral renal artery stenoses in a aged 69 elderly with renal insufficiency, 3 antihypertensive medications, BP 178/88mmHg, Cr 187 umol/l Follow-upOne antihypertensive drug 3 days BP134/82mmHg,Cr132umol/l 14 days BP132/84mmHg,Cr118umol/l6 mons BP128/72mmHg,cr107umol/l12

29、mons BP126/76mmHg,cr112umol/l肾血管病的处理62Case 1: Bilateral renal arte Male, 61yr，Hypertension10yr，BP180/110mmHg with five antihypertensive medications. CHD, 2 years ago LAD PCI, Smoking, Hyperlipidimia SCr 205umol/l3 days after procedure BP132/84mmHg with two antihypertensive medications SCr128umol/l24

30、 months after procedure BP124/72 84mmHg with two antihypertensive medications SCr116umol/l肾血管病的处理63 Male, 61yr，Hypertension10yr，64-slices CTA finding on a female, 65 yo. High blood pressure 20 years ,Maximal BP 210/120mmHG, out of control with nifedipine IGTS 30mg qd, bisoprolol 5mg qd, and perindop

31、ril 4mg qd, for 5 years, Exacerbate 3m肾血管病的处理6464-slices CTA finding on a fe肾血管病的处理65肾血管病的处理65结论我们的单中心研究表明支架置入重建血运治疗粥样硬化性肾动脉严重狭窄有较好的安全性，中远期降压和稳定肾功能的获益肯定。本研究也提示肾动脉支架术有可能显著减少心血管事件的发生率并降低死亡率，但还需要进一步研究予以证实。 肾血管病的处理66结论我们的单中心研究表明支架置入重建血运治疗粥样硬化性肾动脉阜外医院肾动脉狭窄研究的现状1999-至今已积累550例肾动脉介入病例。近年来新来我院诊治的肾动脉狭窄患者300例/

32、年以上，实施介入治疗病例150例/年，欧美国家达到如此规模的医学中心不到5家。 肾血管病的处理67阜外医院肾动脉狭窄研究的现状1999-至今已积累550例肾动肾动脉介入治疗的现状技术成功率有效率并发症围手术期死亡率阜外医院99%86.7%3.6%0.4%国际文献95100%5076%415%0.31%肾血管病的处理68肾动脉介入治疗的现状技术成功率有效率并发症围手术期死亡率阜外以肾功能不全的进展率为主要终点事件的研究，如果要取得阳性结果，则需要满足二个关键点：1.病例入选要严格，即双侧或单功能肾的肾动脉严重狭窄（70%）所致的缺血性肾病。对于单侧肾动脉狭窄,患肾较对照侧肾功能下降至少25% 。

33、2. 从事肾动脉介入的治疗团队富有经验，能有效防范介入对肾脏直接损害。 肾血管病的处理69以肾功能不全的进展率为主要终点事件的研究，如果要取得阳性结以控制高血压为目的的肾动脉支架术如果入选标准定在肾动脉直径狭窄50%，可能包括部分没有血流动力学意义的狭窄(50-70%)，肾动脉支架术不但无效，而且要承担介入治疗本身的风险。实践表明，入选患者要满足二个关键点：1. 肾动脉狭窄70%，且能证明狭窄与高血压存在因果关系；2. 顽固性高血压或不用降压药高血压达III级水平。 肾血管病的处理70以控制高血压为目的的肾动脉支架术如果入选标准定在肾动脉直径狭如何保证肾动脉支架术疗效?1.严格把握肾动脉介入的

34、适应征2.防范介入对肾脏的直接损害，提高手术成功率。 肾血管病的处理71如何保证肾动脉支架术疗效?1.严格把握肾动脉介入的适应征肾动脉支架术后急性肾功能损害的主要原因1. 介入操作过程中发生的肾动脉栓塞 及其它损伤；2. 造影剂诱发的肾毒性；3. 血容量不足导致的肾灌注不足。 肾血管病的处理72肾动脉支架术后急性肾功能损害的主要原因1. 介入操作过程中发重视控制危险因素ARVD是全身动脉粥样硬化的一部分，肾动脉支架术成功并不意味着动脉粥样硬化进程的终止。降脂治疗、降糖治疗、降压治疗及阿斯匹林等对防止动脉粥样硬化发展有深远的影响，对预防心血管并发症有重大意义，应予高度重视。 肾血管病的处理73重

35、视控制危险因素ARVD是全身动脉粥样硬化的一部分，肾动脉支纤维肌性结构不良(FMD)及大动脉炎所致的肾动脉狭窄 PTA的指征相对宽松 ： 1.肾动脉狭窄50%; 2.持续高血压160/100mmHg大动脉炎活动期不宜手术，一般要用糖皮质激素治疗使血沉降至正常范围后2个月以上方可考虑行PTA 一般不使用血管内支架, 仅作为PTA失败的补救措施 : 1.单纯PTA治疗FMD及大动脉炎的结果很好; 2.这类病变放置支架远期结果并清楚。 肾血管病的处理74纤维肌性结构不良(FMD)及大动脉炎所致的肾动脉狭窄 PTA Clinical outcomes of PTRA as Treatment for

36、Renal Artery Stenosis caused by aortoarteritis or FMDJiang Xiongjing, et al. Hypertension Division, Cardiovascular Institute and Fu Wai Hospital, CAMS and PUMC肾血管病的处理75 Clinical outcomes of PTRA asMETHODPatients selection for PTRAIn presence of renal artery 60% diameter stenosis,Patients had Poorly

37、controlled hypertension while receiving 3 antihypertensive medications or HBP grade III without antihypertensive medications. a. Increased renal vein renin b. Captopril Renoscitigraphy Positive c. serum creatinine level30% residual stenosis after PTA e. Longitudinal kidney length 7.0cm with GFR10ml/

38、minIndications for inclusion were not mutually exclusive.肾血管病的处理76METHODPatients selection for Clinical characteristics of 80 study patientsGENDER(m/f) 28/52AGE(YR) 1358 (29 14) ETIOLOGY(N) FIBROMUSCULAR DYSPLASIA 18(22.5%) ARTERITIS 62 (77.5%)Lesions stenoses(%) 60%100% (82 15) 肾血管病的处理77Clinical ch

39、aracteristics of 80Blood pressure response (SBP/DBP, mmHg) after PTRA baseline discharge 6month Arteritis 174.532.8/ 106.820.4 129.221.6/80.211.5* 134.625.3/83.413.6 *#FMD 156.426.8/ 104.612.4 126.415.2/75.69.8* 128.817.6/76.210.4 * No.of med 2.91.3 1.01.1 * 1.21.4*# *P0.001compared with baseline. #

40、 P0.05 compared with values at discharge. SBP= systolic blood pressure; DBP=diastolic blood pressure 肾血管病的处理78Blood pressure response (SBP/DThe effect of PTRA on hypertension at 6-month follow-up Etiology Cure(%) Improved(%) No improvement(%) Total (%) Arteritis 35(56.5) 19 (30.6) 8(12.9) 62 (100) FMD 14 (77.8) 3 (16.7) 1 (5.6) 18 (100) Cure:SBP140mmHg & DBP10% or DBP15% with taking same medications, SBP10% or DBP15% with taking fewer medications; No improvement: the aforementioned criteria were not met.Estimated restenosis rate: 8 pts with arteritis & 1 pts with FMD肾血管病的处理79The ef