肾血管病的处理课件

ManagementofRenovascularHypertension

阜外心血管病医院心内科蒋雄京

InterrelationamongRenalArteryStenosis,Hypertension,andChronicRenalFailure

DefinitionofRenalArteryStenosis

Renalarterystenosis(RAS)isdefinedasnarrowingofthelumen

oftherenalartery.

*angiographicdiameterstenosis>50%

*translesionalpressuregradientof>20

mmHgpeaksystolic

or10mmHgmean

ThemostcommoncausesofRASareatherosclerosis(>80%),aortoarteritis(<15%),andfibromusculardysplasia(<5%)inChina

AngiographicAppearanceoftheThreeCommonFormsofRenalArteryStenosisPrevalence1.1~3%inhypertensivepopulation2.20~30%inpatientswithsecondaryhypertensionIncidenceofRenalArteryStenosis

atCardiacCatheterization

AuthorsYearCountryPatientsAgeCAD(%)HT(%)RAS(%)Crowley1998USA141526189726.3Conlon2000Ireland398752100586.3Weber2002Austriamashita2002Japan2896676487Rihal2002USA29765NA10019.2Buller2004Canada83767683214.3Addad2005Tunisia30058100359CAD=Coronaryarterydisease;HTN=Hypertension;RAS=significantrenalarterystenosis;NA=nonavailable.IncidenceofRenalArteryStenosisatCardiacCatheterization

inChinesepopulation

StudyAuthorsZhangetalPts,n

1200RAS>50%9.7Bilateral,%1.7IndicationSuspectedCHDWangetal23014.8NRCHDShenetal28015.35.0SuspectedCHDLiuetal14118.4NRSuspectedCHDMean185111.8NRProgressiveAtherosclerosis,RenalArteryStenosis,andIschemicNephropathy

theclinicalmanifestationsofARVDClinicalfeaturessuggestiveofrenovascularhypertension

JNC-VI

Onsetofhypertensionaged<30y;Abdominalbruit;Acceleratedorresistanthypertension;Flashpulmonaryedemawithnormalleftventricularfunction;Renalfailureofuncertaincause;Coexisting,diffuseatheroscleroticvasculardiseaseAcuterenalfailureprecipitatebyantihypertensivetherapy,particularlyACEIorAIIreceptorblockers;InthepresenceoftheseclinicalcluestheprevalenceofRVHis<40%.ScreeningforRenovascularHypertension1.Radionucliderenalfractionalflow/GFR2.Plasmareninactivity3.Captoprilrenoscitigraphy4.Colordopplorultrasonography5.MRAngiography/CTAngiographyMulti-slicesCTAismostusefulforRASscreeningSeverityofrenalvasculardiseasepredictsmortalityinpatientsundergoingcoronaryangiographyKidneyInternational(2001)60,1490–1497

ClinicalCriteriaforRevascularizationHypertension:acceleratedhypertension;refractoryhypertension;malignanthypertension;hypertensionwithaunilateralsmallkidney;or

hypertensionwithintolerancetomedication.

Renalsalvage:

suddenunexplainedworseningofrenalfunction;

impairment

ofrenalfunctionsecondarytoantihypertensivetreatment,

particularly

withanangiotensin-convertingenzymeinhibitor

orangiotensin

IIreceptorblocker;orrenaldysfunction

notattributable

toanothercause.

Cardiacdisturbancesyndromes:recurrent

"flash"pulmonaryedema

outofproportiontoanyimpairment

ofleftventricularfunction,orunstableangina

inthesettingofsignificantRAS.MedicalTherapy

controlofbloodpressure:ACEinhibitorsorAngiotensinreceptorblockers?antiplatelettherapysmokingcessationaggressivecontrolofhyperlipidemiaandDMThebestmedicaltherapyforARVDremainsunclear.MedicaltherapyhardlypreventsrenalfunctionworseninpatientswithbilateralRASorRASofsinglekidney.

ChabovaV,etal.

MayoClinProc2000;75:437-444BaboolalK

AmJKidneyDis1998;31:971-977肾动脉支架置入meta-analysisdatademonstratingsuperiorityofrenalarterystentcomparedwithballoonangioplastyforproceduresuccessandrestenosisrates

阿斯匹林0.1~0.3QD,氯吡格雷75mgQD，2-3天;降压,血压控制在<160/100mmHg；碘过敏试验;EndovascularTreatmentofRenalArteryStenoses1.ThroughafemoralaccessEmerald.035.014Stabilizer+6FBriteTipSheath55cmEndovascularTreatmentofRenalArteryStenoses2.ThroughabrachialaccessTempo4FMP+.014StabilizerRenalArteryStentingCasereport-1女，60岁，发现高血压2年，最高200/120mmHg。反复出现胸闷，夜间阵发性呼吸困难，不能平卧，双下肢浮肿。二型糖尿病10年。用药：蒙诺10mgQd，波依定5mgQd，寿比山2.5mgQd，血压一般控制在150/90mmHg左右。血肌酐244umol/L,尿素氮22.9mmol/L,K+5.76mmol/L,GLU8.09mmol/L，尿〔-〕胸片示双肺淤血，右侧少量胸腔积液，UCG示左房前后径45mm，左室舒张末期前后径61mm，EF43%冠脉造影〔-〕MRA双肾动脉近段重度狭窄〔>90%〕肾γ照相〔99mTc-DTPA〕ARVD–RandomizedStudiesPTRAvsMedication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FMD50–85%85-100%ARAS5–15%50–70%TA40-60%75-90%ASTRALAngioplastyandSTentforRenalArteryLesionsUKMULTI-CENTRETRIALIN

ATHEROSCLEROTICRENOVASCULARDISEASEPhilipAKalraLeadNephrologistforASTRAL,HopeHospital,Salford,UK,OnbehalfoftheASTRALTMCandcollaboratorsASTRALTrial:

Design806403MedicalRx

403StentAssigned308Stent(76%)44NotAttempted17Failed34NotKnownPrimaryandsecondaryendpointsinASTRAL

Primaryendpoint

Secondaryendpoints

BloodpressurecontrolRenalevents(suchasacuterenalfailure,dialysis,transplantornephrectomy)Seriousvascularevents(suchasmyocardialinfarction,anginaorstroke)MortalityRateofprogressionofrenaldysfunction(usingserumcreatinineanalysedbyreciprocalcreatinineplotsovertime)

StentMedRxpValueAge7071NSMale63%63%NSDiabetes31%29%NSCr179178NSGFR4039NSBilateral50%50%NSACE/ARB47%38%NSBaselineCharacteristics

ASTRAL:LesionSeverityMean=76%(Range:20%–100%)Sitereported:nocorelabNo.ofpatientsStenosis(%)ASTRAL:

TreatmentRevascularizationStrategies:•Stenting93%•PTAalone7%•Post-stentresidualstenosis>50%:

12%•Complications:7%–Perforations:4(1%)–CholesterolEmboli3(1%)–Death<30daysofstent:2(0.5%)ASTRAL:

PrimaryEndpoint,1/Cr7.507.006.506.005.505.000612182430364248RevascularisationMedicalManagementMonthsfromRandomisation4033393202842201328440334832829921513077RevascularisationMedicalP=nsASTRAL:

ChangeinSystolicBPP=ns1050-5-10-15-2010730-3-7-10612182430364248612182430364248MonthsfromRandomisationRevascularisationMedicalManagementMeanChangeinSystolicBPTreatmentDifferenceRevascularisation:38433031527421613783Medical:38834132729021112781ASTRALEventComposite:

MI,StrokeVascularDeathHospitalizationforAngina,FluidOverloadorCHF以前的RCT研究ASTRAL

经皮肾动脉成形联合药物治疗优于单纯药物治疗未能证明支架+药物治疗药物治疗EffectivenessofManagementStrategiesforRenalArteryStenosis质疑-1806403MedicalRx

403StentAssigned308Stent(76%)44NotAttempted17Failed34NotKnown质疑-2入选标准太宽，大局部病例的肾动脉狭窄不能肯定是否有功能意义.

ASTRALTrial:Design1)with≥1ARVDlesion,and2)inwhom“substantialuncertaintyaboutwhetherearlyrevascularizationisclinicallyindicated.Inparticularitshouldbeunlikelythatrevascularizationwillbecomedefinitelyindicatedwithinthenext6months.〞ASTRAL:LesionSeverityMean=76%(Range:20%–100%)Sitereported:nocorelabNo.ofpatientsStenosis(%)•MedicaltherapyAssociatedwithprogressivedeclineinrenalfunction•StentingBeneficialeffectonslopeof1/Cr“Stabilization〞ChabovaMayoClinProc2000;75:437-44.HardenLancet1997;349:1133-1136.WatsonCirc2000;102:1671-7.76543210-600-500-400-300-200-1000100200300400500600SerumcreatinineX10-3药物治疗与介入治疗的随机比照研究

可靠吗？最大问题是方法学上的可比性差：药物治疗组在不同中心的质控可保持根本一致，但介入治疗组由于不同中心的研究团队水平差异，质控很难保持一致，对结果影响很大.ASTRAL等随机临床研究的启示

经皮支架重建血运治疗粥样硬化性肾动脉狭窄的中远期临床结果

中国医学科学院北京协和医学院阜外心血管病医院

蒋雄京杨倩杨跃进吴海英张慧敏惠汝太高润霖有效？无效？本研究报告我院近5年来连续238例ARAS患者经皮支架置入重建肾动脉血运的中远期临床结果，对该问题作一探讨。资料与方法本研究病例入选标准：(1)肾动脉主干或主要分支直径狭窄≥60%，如直径狭窄仅为60%~75%，那么必须具备狭窄远、近端压差≥30mmHg或卡托普利肾图阳性(2)未服降压药时血压>180/110mmHg或正规三联降压药治疗血压>140/90mmHg；(3)血肌酐<264μmol/L；(4)患肾长度>7.0cm，并且剩余的GFR>10ml/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结果-患者的根本临床特征患者(n=238)的基线临床特征年龄(岁)33～83(64.2±9.5)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(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(NYHAⅢ～Ⅳ级),例(%)17(7.1)结果-患者的根本临床特征患者(n=238)的基线临床特征(续)高血压病史(月)1～600(159.5±143.9)收缩压(mmHg)161.6±22.2舒张压(mmHg)94.6±8.8服用降压药种类数(种)1～5(2.9±1.6)狭窄程度(%)60～100(82.9±8.1)单侧肾动脉狭窄,例(%)172(72.3)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)0～2.45(1.0±0.5)血肌酐水平(umol/L)44.0～263.92(108.9±42.3)

血肌酐＜133umol/L,例(%)202(84.9)

血肌酐133～177umol/L,例(%)26(10.9)

血肌酐＞177umol/L,例(%)10(4.2)血尿素水平(mmol/L)

2.9～23.8(7.5±3.3)PTRAS的造影和支架结果及并发症

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6～72(29.2±19.6)个月，共失访23例(9.7%)PTRAS对血压的影响临床判定的支架内再狭窄率3.0%(7/238)PTRAS对肾功能的影响PTRAS后血压和肾功能转归

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(83.2)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)本研究PTRAS后的无事件生存率SeverityofrenalvasculardiseasepredictsmortalityinpatientsundergoingCAGKidneyInternational(2001)60,1490–1497PTRAS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%)

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(0.000-0.151)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)0.019Case1:Bilateralrenalarterystenosesinaaged69elderlywithrenalinsufficiency,3antihypertensivemedications,BP178/88mmHg,Cr187umol/l

Follow-upOneantihypertensivedrug3daysBP134/82mmHg,Cr132umol/l14daysBP132/84mmHg,Cr118umol/l6monsBP128/72mmHg,cr107umol/l12monsBP126/76mmHg,cr112umol/lMale,61yr，Hypertension>10yr，BP180/110mmHgwithfiveantihypertensivemedications.CHD,2yearsagoLADPCI,Smoking,HyperlipidimiaSCr205umol/l3daysafterprocedureBP132/84mmHgwithtwoantihypertensivemedicationsSCr128umol/l24monthsafterprocedureBP124/7284mmHgwithtwoantihypertensivemedicationsSCr116umol/l64-slicesCTAfindingonafemale,65yo.Highbloodpressure20years,MaximalBP210/120mmHG,outofcontrolwithnifedipineIGTS30mgqd,bisoprolol5mgqd,andperindopril4mgqd,for5years,Exacerbate3m

结论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/年以上，实施介入治疗病例>150例/年，欧美国家到达如此规模的医学中心不到5家。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95~100%50~76%4~15%0.3~1%

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，那么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%。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。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.血容量缺乏导致的肾灌注缺乏。重视控制危险因素纤维肌性结构不良(FMD)及大动脉炎所致的肾动脉狭窄

ClinicaloutcomesofPTRAasTreatmentforRenalArteryStenosiscausedbyaortoarteritisorFMDJiangXiongjing,etal.

HypertensionDivision,CardiovascularInstituteandFuWaiHospital,CAMSandPUMCMETHOD

PatientsselectionforPTRAInpresenceofrenalartery>60%diameterstenosis,PatientshadPoorlycontrolledhypertensionwhilereceiving3antihypertensivemedicationsorHBPgradeIIIwithoutantihypertensivemedications.a.Increasedrenalveinreninb.CaptoprilRenoscitigraphyPositivec.serumcreatininelevel<264umol/L(3.0mg/dl)d.StentingIncaseof>30%residualstenosisafterPTAe.Longitudinalkidneylength>7.0cmwithGFR>10ml/minIndicationsforinclusionwerenotmutuallyexclusive.Clinicalcharacteristicsof80studypatientsGENDER(m/f)28/52AGE(YR)13~58(2914)

ETIOLOGY(N)

FIBROMUSCULARDYSPLASIA18(22.5%)ARTERITIS62(77.5%)Lesionsstenoses(%)60%~100%(8215)

Bloodpressureresponse(SBP/DBP,mmHg)

afterPTRA

baselinedischarge6monthArteritis174.5±32.8/106.8±20.4129.2±21.6/80.2±11.5*134.6±25.3/83.4±13.6*#FMD156.4±26.8/104.6±12.4126.4±15.2/75.6±9.8*128.8±17.6/76.2±10.4*

No.ofmed2.9±1.31.0±1.1*1.2±1.4*#

*P<0.001comparedwithbaseline.#P<0.05comparedwithvaluesatdischarge.SBP=systolicbloodpressure;DBP=diastolicbloodpressureTheeffectofPTRAonhypertensionat6-monthfollow-up

EtiologyCure(%)Improved(%)N