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Renal Artery Stenosis: Prevalence and Associated Risk Factors in Patients Undergoing Routine Cardiac

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Renal Artery Stenosis: Prevalence and Associated Risk Factors in Patients Undergoing Routine Cardiac Renal Artery Stenosis: Prevalence and Associated Risk Factors in Patients Undergoing Routine Cardiac 1 Michael B. Harding, L. Richard Smith, Stevan I. Himmelstein, Kevin Harrison, Harry R. Phillips, Steve J. Schwab,2 James B. Hermiller, Charles J. Davidson, and Thomas M. Bashore sociated variable. These data reveal the previously MB. Harding, L.R. Smith, SI. Himmelstein, K. Harrison, undetected high prevalence of renal artery disease H.P. Phillips. S.J. Schwab, J.B. Hermiller. C.J. Davidson, in patients undergoing cardiac catheterization and J.M. Bashore, Duke University Medical Center, Dur- provide clinical and angiographic features that as- ham, NC sist in predicting its presence. (J. Am. Soc. Nephrol. 1992; 2:1608-1616) Key Words: Renal artery stenosis, cardiac catheterization, renovascular disease ABSTRACT The purposes of this study were to determine the R enal artery stenosis may be a cause of hyperten- prevalence of angiographically significant renal or- sion and may result in renal ischemia and loss tery stenosis in a patient population referred for di- of renal mass. Stenosis of the renal arteries usually agnostic cardiac catheterization and to develop a results from atheromatous lesions that can bead to model that predicts the highest-risk subset of patients progressive arterial occlusion in many patients ( 1 - 3). Atherosclerotic renovascubar disease is a fre- who have significant renal artery narrowing. A pros- quently overbooked clinical entity and may be a com- pective validation cohort study was undertaken in a mon cause of progressive renal insufficiency (4.5). referral-based university hospital. After left ventricu- Renal artery stenosis is a potentially correctable lography, abdominal aortography was performed problem because revascularization techniques in- to screen for the presence of renal artery disease. A cluding surgery and percutaneous renal artery angio- convenience sample of 1,302 of 1,651 consecutive plasty have been shown to be effective in treating patients undergoing diagnostic cardiac catheteri- renal artery stenosis and preserving renal function zatlon were enrolled In the study. Of the 1,302 ab- (6-11). dominal aortograms performed, I .235 (95%) were The prevalence of renal arterial disease in the gen- deemed of adequate quality for the evaluation of eral population is poorly defined. Necropsy studies suggest a frequency of “severe” stenosis to be 25% in renal artery anatomy. Renal artery disease was iden- subjects 40 yr of age or older (12). Renovascular tlfled In 30% of the patients. Insignificant renal artery hypertension is present in 5 to 1 0% of the total stenosis was found in 187 (15%) and significant hypertensive population, but renal artery stenosis (50% diameter narrowing) stenosis was found in I 88 can be demonstrated in 35 to 43% of patients evalu- (15%). Significant unilateral disease was present in ated for renovascular hypertension ( 1 3. 1 4). The oc- I 1%, and bilateral disease was present in 4%. By currence of renal artery stenosis in patients with unlvariable and multivariable logistic regression atherosclerosis elsewhere, especially in patients with analysis, the association of both clinically and cath- abdominal aortic and aortoiliac disease, is as high as eterlzatlon-derived variables with renal artery dis- 39% (1 5). Small series have also noted significant ease was assessed. Multivariable predictors in- renal artery stenosis in 29% of patients with coro- nary artery disease (16). cluded age, severity of coronary artery disease, The population of patients referred for cardiac congestive heart failure, female gender, and periph- catheterization often exhibits many clinical features eral vascular disease. Hypertension was not an as- that one might anticipate would be associated with atherosclerotic renal artery disease, such as ad- vanced age. evidence of diffuse atherosclerosis, hy- I Rceived September 20. 1991. Accepted January 4. 1992. 2 Correspondenceto Dr. 5.J. Schwab, Duke University MedicalCenter, Box 3014. pertension, renal insufficiency, and the presence of Durham, NC 27710. coronary artery disease (1 2. 1 5- 1 8). Thus, abdominal f046-6673/021 1-1608303.00/0 aortography at the time of cardiac catheterization Journal of the American 5ociety of Nephrology Copyri9ht C 1992 by the American Society of Nephrology provides a low-risk, readily performed means of 1608 Volume 2 - Number II . 1992 Harding et al screening for the presence of renal artery stenosis in phy was performed in the anterior-posterior projec- a population likely to have renal artery disease. tion with lohexol (Omnipaque 350; Winthrop, Bronx, The purpose of this study is twofold. The first is to NY) power injected at a rate of 20 mL/s to a total determine the prevalence of angiographically signif- volume of 30 mL. The injection was recorded on 35- icant renal artery stenosis in a large, diverse popu- mm cine film at 30 frames per second. lation referred for cardiac catheterization. The sec- ond is to develop a model based on clinically and cardiac catheterization-derived parameters that pre- Aortography Analysis dicts the highest-risk subset of patients who have Aortograms were reviewed by a single observer significant renal artery narrowing. thus facilitating blinded to the clinical information. The adequacy of the screening procedure. the study and the presence or absence of renal artery disease were noted. Renal artery percent stenosis METHODS was classified as a minor irregularity (<25% narrow- ing) or 25, 50, 75. 95, or 100% luminal diameter Patient Population narrowing. By convention. an angiographically sig- During a 5-month period, 1 ,302 of 1 .65 1 consecu- nificant lesion was defined as a 50% luminal tive patients undergoing elective diagnostic cardiac diameter narrowing of a major renal artery catheterization at Duke University Medical Center (12,15,16.22-25). Accessory renal arteries with dis- were screened for the presence of renal artery disease ease were felt to be significant if more than one third through the use of abdominal aortography. Patients of the renal mass was estimated to be supplied by not screened were excluded at the discretion of the the vessel. Lesion location was classified as ostial, angiographers. main artery. or branch vessel. Ostial lesions were Before patients had cardiac catheterization. demo- defined as stenotic if the segment of the renal artery graphic data. medical history. physical findings. and lumen immediately contiguous with the aorta was blood chemistries were recorded and entered into a compromised. Lesions of the main segment of the computerized medical information system (19). Pe- renal artery began at least 2 to 3 mm beyond the ripheral vascular disease was defined as a history of ostial segment. Branch lesions were defined as sten- claudication, previous vascular procedure, a history otic lesions originating beyond the first bifurcation of stroke or transient ischemic attack, or physical of the renal artery. The stenotic lesions were desig- evidence of carotid, femoral, or abdominal bruits. nated as atherosclerotic if they did not demonstrate Symptoms of congestive heart failure were recorded a distinctive string-of-beads appearance character- and classified in accordance with the New York Heart istic of fibromuscular dysplasia (26). No complica- Association criteria (20). Hypercholesterolemia was tions related specifically to the aortogram were ob- defined as evidence of a cholesterol level elevated served. Retroperitoneal bleeding (0.002%). laceration above 200 mg/dL. Hypertension was defined as dia- of the femoral artery (0.002%), contrast nephrotox- icity (increase in serum creatinine >0.5 mg/%, 6%; stolic blood pressure >90 mm Hg when subjects were measured as outpatients during the time before >1 mg/%. 1 .4%). and cholesterol embolization in the study group catheterization. Hypertension was also considered (0.00 1 5%) were not increased present if the patient was taking antihypertensive compared with retrospective controls who received cardiac catheterization only. Patients were followed- medications and if it could be confirmed that the Indication for use was hypertension and not angina. up at 24 h and as outpatients. It is reasonable to Blood pressure was measured several times before assume that the risk of renal arteriography is at least as low as combined coronary and renal arteriograpy. and after catheterization but, because of the anxiety and discomfort surrounding the procedure, was not considered as basal blood pressure. Statistical Analysis Stepwise univariate and mubtivariate logistic Angiography regression was performed in order to identify clinical Coronary angiography was performed via femoral and angiographic variables predictive of significant artery approach by the Judkins technique (2 1 ). The renal artery stenosis. A binary logistic model (27) was presence and severity of coronary atherosclerotic le- used to identify univariate predictors of significant sions were determined in the routine fashion. Coro- renal artery stenosis. The variables that were signif- nary artery lesions graded as >70% narrowing of the icant in the univarlate model were then entered into luminal diameter were classified as significant. After a stepwise logistic regression model to identify the left ventriculography. the pigtail catheter was with- best set of independent predictors of significant renal drawn into the abdominal aorta and positioned a few artery stenosis. From these data, a model was devel- centimeters superior to the renal arteries.
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