Patient Selection for Revascularization of Atherosclerotic Renal Artery Stenosis: Comparing the Importance of Stenosis Severity and Clinical Phenotype

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Rationale & Objective Trials failed to show that angioplasty and stenting of atherosclerotic renovascular disease (ARVD) conferred benefit when used as first-line therapy. However, some patients might benefit from kidney revascularization depending on their clinical phenotype and severity of renal artery stenosis (RAS). We investigated this hypothesis further. Study Design Data from the Angioplasty and Stenting for Renal Artery Lesions (ASTRAL) randomized trial and Salford ARVD observational study were included in a single analysis. Setting & Participants Patients were grouped based on RAS severity (≥70%) and whether unilateral or bilateral, with the bilateral group including RAS in a single functioning kidney. High-risk clinical phenotypes included advanced chronic kidney disease (CKD) (estimated glomerular filtration rate < 30 mL/min/1.73 m 2 ), rapid CKD progression (creatinine increase >100 μmol/l or >20% per year), refractory systolic hypertension (≥150 mm Hg on ≥3 agents), and heart failure (chronic or decompensated). Exposures Medical therapy alone versus medial therapy and kidney revascularization. Outcome Composite of end stage CKD, cardiovascular events, or all-cause mortality. Analytical Approach Cox proportional hazard model adjusted for age, self-reported gender, and estimated glomerular filtration rate. Analysis of all patients and selected subgroups. Results In total, 1,644 patients (806 ASTRAL and 838 Salford). Median (IQR) age 72 (66-77) years. For bilateral severe RAS (≥70%) the HR for the composite outcome for revascularization compared with medical therapy was 0.70 (0.50-0.99), P = 0.048. The clinical phenotype where benefit appeared to be greatest in the presence of bilateral severe disease was people with rapidly progressive kidney disease with a HR of 0.39 (0.22-0.71]). In the absence of bilateral severe RAS, there was no benefit to revascularization for any clinical phenotype. Limitations The analyses included observational data. Conclusions The presence of bilateral severe RAS may be the best predictor of benefit for kidney revascularization. Plain-language Summary Previous clinical trials have indicated that undertaking procedures to restore blood flow to narrowed arteries in the kidneys should not be used routinely in patients with this condition (renal artery stenosis). This study looked at whether the procedure would benefit some patients, namely those with high-risk features. It used data from more than 1,000 patients, some of whom had the procedure and some who did not. It found that people with severe narrowing in both kidneys, particularly those who also had heart failure, had better long-term outcomes if they had the procedure. This helps us better understand when the procedure should be used.

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