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Follow-Up on 100 Renal Vein Renin Samplings

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Follow-Up on 100 Renal Vein Renin Samplings Journal of Human Hypertension (2002) 16, 275–280 2002 Nature Publishing Group All rights reserved 0950-9240/02 $25.00 www.nature.com/jhh ORIGINAL ARTICLE Hypertension and renovascular disease: follow-up on 100 renal vein renin samplings P Hasbak1, LT Jensen2, H Ibsen3, and The East Danish Study Group on Renovascular Hypertension* 1Department of Clinical Physiology and Nuclear Medicine, Glostrup Hospital, Denmark; 2Department of Clinical Physiology and Nuclear Medicine, Gentofte Hospital, Denmark; 3Department of Internal Medicine, Glostrup Hospital, Denmark The clinical value of renal vein renin sampling (RVRS) р15%). None of the indices clearly discriminated as a prognostic tool in the treatment of renovascular between the patients who did benefit from intervention, hypertension was evaluated. One hundred consecutive and those who did not. The only positive finding was patients were included over a 4-year period of time. that a peripheral renin concentration lower than 8 mlU/l About half of the patients (49%) were treated inter- predicted no effect of intervention, which might lead to ventionally by PTRA (21%), nephrectomy (20%), or vas- the exclusion of 11% of the patients before entering the cular surgery (8%). Seven patients (15%) were cured and diagnostic programme. We conclude that the RVRS 15 (32%) had improved (reduction in antihypertensive demands a very restrictive referral pattern if it should medicine) after 6 months follow-up, whereas three be of prognostic value for the blood pressure outcome patients (6%) were cured and 12 (26%) improved after after intervention. No indices of lateralised renin con- 3–4 years follow-up. Thus, the number of patients cured centrations proved high predictive value. However, a or improved is comparable with the results from our peripheral renin concentration low in the normal range department reported 20 years ago. However, in the seems useful as an indicator of no benefit from inter- present report, more than twice as many patients were vention. enrolled, leading to double costs. Different indices of Journal of Human Hypertension (2002) 16, 275–280. DOI: lateralisation of the renin generation were calculated for 10.1038/sj/jhh/1001365 the use in cases of a shrunken kidney (functional share Keywords: renovascular hypertension; renal vein renin sampling; cure and improvement rate Introduction tors, in addition to ␤-adrenoreceptor blockers, have made the pharmacological management of arterial More than 20 years ago, the results of interventional hypertension a possible competitor to interventional treatment of renovascular hypertension in our 2,3 1 treatment of renovascular hypertension. Further- department were published. At that time, nephrec- more, the prevalence of renovascular hypertension tomy (82%) and vascular surgery (18%) were the is now estimated to be less than 0.5%4 of the hyper- treatments of choice. Since then, the percutaneous tensive population, in contrast to earlier estimates transarterial renal angioplasty (PTRA) has become up to 5–10%.2 The therapeutic changes combined the preferred treatment of renal artery stenosis. In with the conflicting reports on the clinical useful- the same period of time, the antihypertensive drugs ness of renal vein renin sampling (RVRS) and on the have become increasingly effective. The introduc- long term effects of PTRA on hypertension,5–10 tion of calcium channel blockers and ACE inhibi- recently addressed by van Jaarsveld and col- leagues,11 prompted us to evaluate our strategy in Correspondence: P Hasbak, MD, Department of Clinical Physi- diagnosing and predicting the outcome of inter- ology and Nuclear Medicine, Glostrup Hospital, DK-2600 ventional treatment of renovascular hypertension. Glostrup, Denmark. E-mail: philipȰpost1.tele.dk The study was retrospectively made on 100 con- *Members of the study group: H Dige-Petersen, A Leth, M Brahm, secutive patients who underwent RVRS. The aim of S Schifter, S Rasmussen, Glostrup Hospital; S Strandgaard, S Dorph, F Rasmussen, Herlev Hospital; JK Christoffersen, JO Lund, the study was to investigate if optimisation of indi- S Just, N Baekgaard, LP Jensen Gentofte Hospital; A Høegholm, ces calculated from the RVRS data would improve Naestved Hospital; K Rasmussen, Roskilde Hospital. the prognostic power to predict the outcome of Received 7 August 2001, revised and accepted 29 October 2001 PTRA or nephrectomy on arterial hypertension, and Follow-up on 100 renal vein renin samplings P Hasbak et al 276 to estimate the cost of curing renovascular hyperten- radiologists, who also performed the PTRA pro- sion. cedures, interpreted all angiographies. The RVRS was successful in all patients. Treat- ␣ ␤ Subjects and methods ment with -/ -adrenoreceptor blockers, ACE-I and angiotensin 2 receptor (AT2) antagonists was with- The study population consisted of 100 patients con- drawn for at least 2 weeks prior to RVRS. Owing to secutively referred to Glostrup County Hospital for a thrombotic inferior caval vein, the catheterisation RVRS from 1994 to 1997. For basic data, see Table procedure was performed from the right cubital vein 1. The study was initiated in April 1998, and with in two patients. The remaining patients all had two a late follow-up in 2000. The reference population catheters, from the left and right femoral vein to the was 1.3 million people in the East of Denmark, left and right renal vein. The correct position of the excluding the city of Copenhagen. Approximately catheters was ensured by fluoroscopy, measurement 700000 people were older than 40 years. Thirteen of oxygen tension, and by measuring 51Cr-EDTA in percent (91000 people) received antihypertensive the renal veins in comparison with the reference drugs, with 0.5% of the population (3500 people) sample (iliac vein blood). At start of the procedure, receiving three or more different drugs.12 51Cr-EDTA (3.7 MBq) was given intravenously. Sim- ultaneously blood samples were taken before and after stimulation with furosemide. Plasma renin Diagnostic procedures concentration was determined using the principle of The diagnosis of renovascular hypertension was antibody trapping,14 as modified by Millar et al.15 based on the history of severe hypertension (three The standard renin preparation, 68/356, was or more different antihypertensive drugs/rapid onset obtained from the National Institute for Biological of hypertension), renography, renography with Standards and Control (Hertfordshire, UK) and anti- acute angiotensin-converting enzyme-inhibition bodies against angiotensin I were raised in rabbits. (ACE-I), renal artery angiography and renal vein The decision for a ‘positive RVRS’ was based on a renin sampling. Usually renal artery angiography significant renin gradient across the ipsilateral kid- was carried out before RVRS except in cases where ney and significant suppression of renin secretion the referring physician believed that the outcome of on the contralateral site. An expert panel of phys- RVRS could lead to a decision as far as intervention icians and surgeons made the decision about inter- was concerned. vention after presentation of all clinical and diag- The renographies (without and with acute ACE-I) nostic data. were carried out according to the international rec- ommendations,13 and interpreted by the same panel Follow-up and evaluation of four experts in nuclear medicine. The renal angiographies were made with a right After PTRA, vascular surgery or nephrectomy the and a left view of 15 degrees from centre. In two patients were followed at their local hospital for patients the angiography was not technically poss- blood pressure controls and evaluation. To deter- ible due to extensive atherosclerosis, and in one mine possible benefit of the intervention, the patient patient the angiography was performed via trans- files were reviewed regarding post treatment blood lumbal catheterisation of the aorta, owing to pressure and antihypertensive therapy. If the infor- occlusion of both femoral arteries. The remaining mation was available the blood pressure is given as angiographies were performed with aortic catheris- the mean value of three consultations around the ation from the right femoral artery. The same two time of intervention or RVRS, at 6 months and 3–7 years after intervention/RVRS. A patient was considered ‘cured’ if he/she became normotensive (diastolic blood pressure р90 mm Hg) Table 1 Basic characteristics of the study population in the absence of any antihypertensive medication for at least 6 months. Improvement was defined as Number of patients included 100 Patients excluded 6a a reduction in the need for antihypertensive medi- Study population 94 cation. If none of these conditions were fulfilled the Sex (Female/Male) 37/57 patient’s hypertension was considered ‘unchanged’. Age (years) 58.6 (33.4–84.9)b Blood pressure (mm Hg) Systolic 170 (125–240)b Database, calculations and statistical analysis Diastolic 95 (64–135)b S-creatinine (␮mol/l) 102 (60–536)b Data were collected in a base containing the follow- Antihypertensive medicine ing on each patient: age, gender, serum creatinine one drug 21 (prior to intervention), renography data (functional two drugs 29 three or more drugs 44 share/shape of renograms), renin values from the RVRS (basal conditions and after stimulation with aFour patients died within 6 months, two settled in other areas furosemide), antihypertensive medication (at time of of Denmark. bData are given as median (range). RVRS and at follow up), result of renal angiography, Journal of Human Hypertension Follow-up on 100 renal vein renin samplings P Hasbak et al 277 interventional procedure (PTRA, nephrectomy, vas- was whether a nephrectomy should be performed. cular surgery), and blood pressure (mean of three In all patients, arteriosclerosis was the cause of the consultations before intervention, and at follow up). stenosis, and none due to fibromuscular dysplasia. Four different indices to quantify the lateralis- Interventional treatment was applied in 47 patients ation of the renal renin out-put were calculated, (Figure 1, Table 2) and the result on blood pressure attempting to optimise the prognostic value of the was seven cured, 15 improved and 25 unchanged RVRS (Figure 1).
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