|Year : 2018 | Volume
| Issue : 3 | Page : 875-881
Prevalence and predictors of renal artery stenosis in hypertensive patients undergoing coronary angiography
Mahmoud A Soliman1, Mohamed M Seleem2, Awny G Shalaby1, Ashraf F Abd-Allah2
1 Department of Cardiovascular Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Cardiovascular Medicine, National Heart Institute, Giza, Egypt
|Date of Submission||10-Feb-2017|
|Date of Acceptance||02-May-2017|
|Date of Web Publication||31-Dec-2018|
Ashraf F Abd-Allah
Source of Support: None, Conflict of Interest: None
The aim of the study was to evaluate the prevalence and predictors of renal artery stenosis (RAS) in hypertensive patients undergoing elective coronary angiography.
Hypertension and ischemic nephropathy are the most important consequences of RAS. Ischemic nephropathy progresses to end-stage renal disease in 6–17% of patients. RAS is the most common potentially reversible disorder leading to renal replacement therapy; in recent years, efforts have been made to determine the prevalence of RAS and its predictors among patients with coronary artery disease.
Patients and methods
In a cross-sectional study, between March 2013 and October 2016, 200 hypertensive patients, candidates for diagnostic cardiac catheterization, underwent renal angiography before completion of their coronary angiography procedure. A standardized questionnaire was used to collect demographics, cardiac history, indications for cardiac catheterization, and angiographic data, and RAS result was estimated visually by a skilled cardiologist.
Overall, 200 patients with mean age of 58 ± 7 years were included in the study. Of them, 116 (58%) were male and 84 (42%) were female. The prevalence of RAS was calculated at 22.5%. According to the present study, diabetes mellitus and serum creatinine level were predictors of RAS, whereas other factors included in our study were not.
According to the present data, we suggest considering renal artery angiography in combination with coronary artery angiography especially in hypertensive patients who are diabetic and those with high serum creatinine level.
Keywords: atherosclerosis, coronary angiography, coronary artery disease, hypertension, renal artery stenosis
|How to cite this article:|
Soliman MA, Seleem MM, Shalaby AG, Abd-Allah AF. Prevalence and predictors of renal artery stenosis in hypertensive patients undergoing coronary angiography. Menoufia Med J 2018;31:875-81
|How to cite this URL:|
Soliman MA, Seleem MM, Shalaby AG, Abd-Allah AF. Prevalence and predictors of renal artery stenosis in hypertensive patients undergoing coronary angiography. Menoufia Med J [serial online] 2018 [cited 2019 Jul 20];31:875-81. Available from: http://www.mmj.eg.net/text.asp?2018/31/3/875/248772
| Introduction|| |
Renal artery stenosis (RAS) is defined as narrowing of the renal artery lumen. The most common etiology of RAS is atherosclerosis, which involves the main renal artery.
RAS is the primary cause for nearly 6% of all the cases of end-stage renal disease, which is a life-threatening disease with significant complication,,,,. In addition, RAS is the etiology for 20% of dialysis individuals who are older than 50 years.
RAS is a leading factor for secondary hypertension (HTN), ischemic nephropathy, and end-stage renal disease. Additionally, it is a progressive disease where renal artery perfusion slowly declines and eventually renal function and structure deteriorate.
Individuals with atherosclerotic renal artery stenosis (ARAS) are frequently asymptomatic and have no characteristic laboratory test finding, making its timely diagnosis a major clinical problem. On the contrary, early diagnosis of RAS is of a great importance, as timely intervention can improve clinical outcome. ARAS and coronary artery disease (CAD) are two manifestations of the same pathogenesis, atherosclerosis. Thus, it is not an unusual event that a patient with CAD experiences ARAS and vice versa. Existence of ARAS worsens the CAD course and prognosis. On the contrary, CAD is one of the most important reasons of death in patients with ARAS.
The prevalence of RAS in individuals with suspected CAD who underwent coronary angiography was reported from 11.3 to 39% by some studies. Overall, 1–5% of individuals with blood HTN experience RAS, whereas it is the most common etiology of secondary HTN. Owing to high coexistence of RAS and CAD in cases with angiography-diagnosed CAD, it has been advised that renal angiography be performed in conjunction with coronary angiography.
Therefore, in our study, we aimed to evaluate the prevalence and predictors of RAS in hypertensive patients undergoing elective coronary angiography.
| Patients and Methods|| |
This is a multicenter cross-sectional descriptive–analytical study on the prevalence and predictors of RAS in hypertensive patients undergoing coronary angiography between April 2013 and May 2016 at El Menoufia University and National Heart Institute. The Ethics Committee of El Menoufia University of Medical Sciences approved the study, and written informed consent was obtained from each patient after thorough explanation of the study to patients before enrollment.
In this study, we enrolled a consecutive subset of 200 hypertensive patients who underwent coronary angiography for the detection of suspected CAD. All participants provided details of their demographics; past medical histories of cerebrovascular accident (CVA), pulmonary edema, myocardial infarction (MI), coronary artery bypass (CABG), peripheral arterial disease (PAD), and congestive heart failure (CHF); and medication use at the time of clinical consultation. Cardiovascular risk factors of each patient including diabetes mellitus (DM), dyslipidemia, and smoking were recorded together with precath laboratory test results, especially serum creatinine level and electrocardiographic results. DM was defined as a fasting plasma glucose level of 126 mg/dl or current diabetes treatment with dietary modification, oral glucose lowering agents, or insulin. HTN was defined by the use of antihypertensive medication or systolic blood pressure of 140 mmHg or diastolic blood pressure of 90 mmHg. Dyslipidemia was defined as total cholesterol level of 200 mg/dl or treatment with a lipid-lowering agent. Current smokers or those who had stopped smoking in the previous 3 years were considered smokers. PAD was defined as showing intermittent claudication or a history of lower extremity revascularization.
Patients on renal replacement therapy either renal transplantation or hemodialysis, patients with serum creatinine of greater than 2 mg/100 ml, and patients with acute coronary syndromes or acute heart failure were excluded from this study.
Cardiac catheterization was performed using the femoral approach and the left radial approach. In the first step, coronary angiography was performed, and based on visual estimation by two observers, patients underwent renal angiography before completion of cardiac catheterization.
Renal angiography was performed using a powered injection of 10-ml contrast agent through a Judkin right catheter positioned at the L1 vertebral body level in the straight anteroposterior projection. Selective renal angiography was performed if there was inadequate visualization of renal arteries or if a diagnosis of RAS was in doubt. To prevent contrast-induced kidney injury, patients were hydrated with 1 ml/kg/h saline for 12 h, and diabetic patients or those with serum creatinine level of high normal were treated with N-acetyl cysteine 600 mg twice a day for 2 days. Any degree of RAS was recorded, and a diameter stenosis greater than or equal to 50% based on visual estimation was considered significant RAS. Severe RAS was defined as RAS greater than or equal to 75%. Bilateral RAS was defined as bilateral RAS with at least one RAS greater than or equal to 50%.
Data were analyzed using IBM SPSS statistics (version 23; IBM Corp., Armonk, New York, USA) and MedCalc (version 15; MedCalc Software bvba, Ostend, Belgium). Normality of numerical data distribution was examined using the D'Agostino–Pearson's test. Normally distributed numerical variables were presented as mean ± SD, and intergroup differences were compared using the unpaired t-test. Categorical variables were presented as number and percentage, and intergroup differences were compared using fisher's exact test. Ordinal data were compared using the χ2-test for trend. Correlations were tested using the Spearman rank correlation. Multivariable binary logistic regression analysis was used to identify independent risk factors for RAS. The ‘enter’ method was used to build up the regression model. P value less than 0.05 was considered statistically significant.
| Results|| |
In our study, we enrolled a consecutive subset of 200 [116 (58%) male and 84 (42%) female] patients, with a mean age of 58 ± 7 years: 102 (51%) diabetic patients, 122 (61%) with patients with dyslipidemia, 118 (59%) patients were smokers, 176 patients with abnormal rhythm [NSR: 161 (80.5%) and atrial fibrillation: 15 (7.5%)], left bundle branch block 24 (12%) patients, history of CHF in 3 (1.5%) patients, history of pulmonary edema in 49 (24.5%) patients, history of percutaneous coronary intervention in 32 (16%) patients, history of MI in 97 (48.5%) patients, patients with PAD 17 (8.5%), patient with CVA 14 (7%), patients with history of CABG two (1%), patient with normal coronary vessels three (1.5%), patients with one diseased coronary vessel 14 (7%), patients with two diseased coronary vessels 49 (24.5), patients with three diseased coronary vessels 52 (26%), and patients with four diseased coronary vessels 82 (41%), as shown in [Table 1].
Our study group consisted of two major groups: 155 (77, 5%) patients with normal renal arteries (non-RAS group) and 45 (22.5%) patients with diseased renal arteries (RAS group) [Figure 1].
|Figure 1: Prevalence of renal artery stenosis (RAS) among the study population.|
Click here to view
In our study, patients within the RAS group were subdivided into four subgroups as follow: 17 (8.5%) patients with mild (stenosis: <50%) RAS, 10 (5%) patients with moderate (stenosis: 50–75%) RAS, two (1%) patients with severe (stenosis: >75%) RAS, and 16 (8%) patients with bilateral RAS [Table 1] and [Figure 2].
|Figure 2: Grading of renal artery stenosis (RAS) in the study population.|
Click here to view
On analysis of characteristics of whole study population regarding the numerical variables, it revealed that the mean age in the whole study population was 58 ± 7 years, with minimum of 40 years and maximum of 72 years, and mean serum creatinine level was 1.0 ± 0.2 mg/dl, with maximum of 1.4 mg/dl and minimum of 0.6 mg/dl [Table 2].
There were no significant differences between the two major groups for sex, smoking, history of CHF, rhythm, history of CABG, history of MI, PAD, CVA, and history of pulmonary edema. The significant difference between the two groups regarding DM (P = 0.000001), dyslipidemia (P = 0.000009), number of risk factors (DM, dyslipidemia, and smoking) (P = 0.000003), history of MI (P = 0.007), number of diseased coronary vessels (P = 0.035), and serum creatinine levels (P = 0.000000003) [Table 3] and [Figure 3].
|Table 3: Comparison of patients with or without renal artery stenosis: categorical and numerical variables|
Click here to view
|Figure 3: Prevalence of relevant risk factors among patients with or without renal artery stenosis (RAS).|
Click here to view
When coronary angiographic characteristics of the study population were evaluated, the prevalence of single-vessel, two-vessel, or three-vessel disease was more prevalent in the group with RAS as follows: one (2.2%) patient among RAS group has no diseased coronary vessels, two (4.4%) patients among RAS group have one diseased coronary vessel, six (13.3%) patients among RAS group have two diseased coronary vessels, 11 (24.4%) patients among RAS group have three diseased coronary vessels, and 25 (55.6%) patients among RAS group have four diseased coronary vessels [Figure 4] and [Table 3].
|Figure 4: Number of diseased coronary arteries in patients with or without renal artery stenosis (RAS).|
Click here to view
To determine the independent predictors for the presence of RAS, we performed multivariate logistic regression on serum creatinine level, DM, dyslipidemia, number of risk factors (DM, dyslipidemia, and smoking), number of diseased coronary arteries, and history of MI, and the results of multivariate logistic regression analysis revealed that only serum creatinine level (P = 0.0001) and DM (P = 0.008) were independent risk factors for RAS [Table 4]. Moreover, there were no complications attributed to the renal and/or coronary angiography.
|Table 4: Multivariable binary logistic regression analysis for predictors of renal artery stenosis|
Click here to view
Overall fit of the multivariable binary logistic regression model for determinants of RAS was done, and the model had good overall fit with a sensitivity of 80% and specificity of 80.7% for prediction of RAS among diabetic patients and patients with high normal serum creatinine levels [Table 5] and [Figure 5].
|Table 5: Overall fit of the multivariable binary logistic regression model for determinants of renal artery stenosis|
Click here to view
|Figure 5: Receiver-operating characteristic curve derived from the multivariable binary logistic regression model for determinants of renal artery stenosis.|
Click here to view
| Discussion|| |
The reported prevalence of significant RAS (>50%) among patients undergoing coronary angiography ranges from 6.2% to as high as 28%,. A positive association between the presence and severity of RAS and CAD has been described, and the presence of RAS has been associated with poor cardiovascular outcome. There is growing evidence that a high percentage of significant ARAS is clinically indolent,.
We worked in this study to assess the prevalence of RAS in patients with HTN and suspected CAD who are candidates for coronary angiography. We also aimed to clarify RAS predictors in our study group.
In this study, we investigated 200 hypertensive patients who were suspected for CAD and underwent simultaneous coronary and renal artery angiography and found that the prevalence of RAS in this population was 22.5%, which was nearly high. Overall, 14.5% of the study population had unilateral RAS, whereas 8% of them experienced bilateral RAS. In the study conducted by Rokni et al., the prevalence of RAS was reported to be 40%. This high prevalence in this study is because most of their cases that underwent renal angiography experienced resistant HTN and renal dysfunction, whereas in our study population, there were no renal impairment patients (the maximum estimated serum creatinine level was 1.4 mg/dl). In other studies conducted by Rimoldi et al., Shah et al., Yamashita et al., Rihal et al., Dzielinska et al., Yorgun et al., and Payami et al., the prevalence of RAS in hypertensive patients who were referred for coronary angiography was reported as 8, 11, 13, 19.2, 12, 28.8, and 18.2%, respectively. These differences in the reported prevalence from various studies is partly related to the demographic differences including difference in participants mean age and existence or absence of underlying diseases which worsen atherosclerosis. Accordingly, this discrepancy between results is partly attributed to the ethnical, regional, and lifestyle pattern differences. High prevalence of atherosclerotic risk factors in our society, low activity in large spectrum of people as well as atherogenic diet can justify this high prevalence of RAS, which is reported by our study.
In our study, there were no significant differences between the two major groups (RAS and non-RAS groups) regarding sex, smoking, history CHF, rhythm, history of CABG, history of MI, PAD, CVA, and history of pulmonary edema. There were significant difference between the two groups regarding diabetes, dyslipidemia, number of risk factors, history of MI, number of diseased coronary vessels, and serum creatinine level, which was in line with general risk factors for atherosclerotic process. This result was in agreement with Ghaffari et al. except in case of previous history of CABG, CHF, and pulmonary edema together with atrial fibrillation, which may be because of wider scale of study.
In the present study, age had no difference between the two major groups (RAS and non-RAS group), and that did not match with the results of Shukla et al. and Bageacu et al., which might be because of the large number of study patients enrolled in these studies.
When coronary angiographic characteristics of the study population were evaluated, the prevalence of single-vessel, two-vessel, or 3-vessel disease was more prevalent in the groups with RAS. In our study, the prevalence of RAS increased with the increased extent of CAD as follow: one (2.2%) patient among RAS group has no diseased coronary vessels, two (4.4%) patients among RAS group have one diseased coronary vessel, six (13.3%) patients among RAS group have two diseased coronary vessels, 11 (24.4%) patients among RAS group have three diseased coronary vessels, and 25 (55.6%) patients among RAS group have four diseased coronary vessels, which was in agreement with Yorgun et al., Ollivier et al., and Przewłocki et al. who found a correlation between extent of CAD and severity with RAS.
In the current study, the grade of RAS showed increased correlation with number of risk factors (DM, smoking, and dyslipidemia) and serum creatinine level, which was in agreement with Weber-Mzell et al..
To determine the independent predictors for the presence of RAS, we performed multivariate logistic regression analysis on serum creatinine level, DM, dyslipidemia, number of risk factors (DM, dyslipidemia, and smoking), number of diseased coronary arteries, and history of MI. The results of multivariate logistic regression analysis revealed that only serum creatinine level and DM were independent risk factors for RAS, which was in agreement with Zhang et al. and in contrast to results in different studies such as Park et al. who revealed that CAD, renal insufficiency, age, and hypercholesterolemia were independent predictors for the presence of RAS, whereas Payami et al. revealed that smokers and heart failure were independent predictors for the presence of RAS, which was partly attributed to the ethnical, regional, and lifestyle pattern differences and difference of subset inclusion criteria and exclusion criteria in each study.
| Conclusion|| |
The prevalence of significant RAS in our patients is similar to that reported in western countries and is ~22.5% in hypertensive patients referred for coronary angiography. We found that the prevalence of RAS increases with the severity of CAD. DM, dyslipidemia, serum creatinine level, history of MI, and number of diseased coronary vessel are more common in patients with significant RAS. In multivariate logistic analysis, DM and serum creatinine concentration were independent predictors of RAS. The results of upcoming randomized trials will determine appropriate candidates for RAS screening and suggest who will benefit from revascularization.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chrysochou CK. Current management of atherosclerotic renovascular disease what have we learned from ASTRAL? Nephron Clin Pract 2010; 115
Plouin PF, Bax L. Diagnosis and treatment of renal artery stenosis. Nature Rev Nephrol 2010; 6
Beladi-Mousavi SS, Alemzadeh-Ansari MJ, Alemzadeh-Ansari MH, Beladi-Mousavi M. Long-term survival of patients with end-stage renal disease on maintenance hemodialysis: a multicenter study in Iran. Iran J Kidney Dis 2012; 6
Tamadon MR, Beladi-Mousavi SS. Erythropoietin; a review on current knowledge and new concepts. J Renal Inj Prev 2013; 2
Beladi-Mousavi SS, Beladi-Mousavi M, Hayati F, Talebzadeh M. Effect of intranasal DDAVP in prevention of hypotension during hemodialysis. Nefrologia 2012; 32
Beladi-Mousavi SS, Sametzadeh M, Hayati F, Fatemi SM. Evaluation of acquired cystic kidney disease in patients on hemodialysis with ultrasonography. Iran J Kidney Dis 2010; 4
Beladi-Mousavi SS, Alemzadeh-Ansari MJ, Cheraghian B. Outcome of patients on haemodialysis in Khuzestan, Iran. NDT Plus 2011; 4
Rihal CS, Textor SC, Breen JF, McKusick MA, Grill DE, Hallett JW, et al.
Incidental renal artery stenosis among a prospective cohort of hypertensive patients undergoing coronary angiography. Mayo Clin Proc 2002; 77
Weber-Mzell D, Kotanko P, Schumacher M, Klein W, Skrabal F. Coronary anatomy predicts presence or absence of renal artery stenosis. A prospective study in patients undergoing cardiac catheterization for suspected coronary artery disease. Eur Heart J 2002; 23
Rokni N, Salarifar M, Kazazi EH, Goodarzynejad H. Frequency and predictors of renal artery stenosis in patients undergoing simultaneous coronary and renal catheterization. J Tehran Heart Cent 2012; 7
Ollivier R, Boulmier D, Veillard D, Leurent G, Mock S, Bedossa M, Le Breton H. Frequency and predictors of renal artery stenosis in patients with coronary artery disease. Cardiovasc Revasc Med 2009; 10
Dzielinska Z, Januszewicz A, Demkow M, Makowiecka-Cieśla M, Prejbisz A, Naruszewicz M, et al.
Cardiovascular risk factors in hypertensive patients with coronary artery disease and coexisting renal artery stenosis. J Hypertens 2007; 25
Mui KW, Sleeswijk M, van den Hout H, van Baal J, Navis G, Woittiez AJ. Incidental renal artery stenosis is an independent predictor of mortality in patients with peripheral vascular disease. J Am Soc Nephrol 2006; 17
Zhang Y, Ge JB, Qian JY, Ye ZB. Prevalence and risk factors of atherosclerotic renal artery stenosis in 1200 Chinese patients undergoing coronary angiography. Nephron Clin Pract 2006; 104
Rimoldi SF, de Marchi SF, Windecker S, Meier B, Allemann Y. Screening renal artery angiography in hypertensive patients undergoing coronary angiography and 6-month follow-up after ad hoc percutaneous revascularization. J Hypertens 2010; 28
Shah SS, Noor L, Sawar S, Awan ZA, Hafeezullah M, Khan SB. Frequency and predictors of renal artery stenosis in patients with coronary artery disease. J Ayub Med Coll Abbottabad 2010; 22
Yamashita T, Ito F, Iwakiri N, Mitsuyama H, Fujii S, Kitabatake A. Prevalence and predictors of renal artery stenosis in patients undergoing cardiac catheterization. Hypertens Res 2002; 25
Yorgun H, Kabakçi G, Canpolat U, Aytemir K, Fatihoglu G, Karakulak UN, et al.
Frequency and predictors of renal artery stenosis in hypertensive patients undergoing coronary angiography. Angiology 2013; 64
Payami B, Jafarizade M, Beladi Mousavi SS, Sattari S-A, Nokhostin F. Prevalence and predictors of atherosclerotic renal artery stenosis in hypertensive patients undergoing simultaneous coronary and renal artery angiography; a cross-sectional study. J Renal Inj Trev 2016; 5
Ghaffari S, Sohrabi B, Siahdasht RB, Pourafkari L. Prevalence and predictors of renal artery stenosis in hypertensive patients undergoing coronary angiography. Hypertens Res 2009; 32
Shukla AN, Madan TH, Jayaram AA, Kute VB, Rawal JR, Manjunath A, et al.
Prevalence and predictors of renal artery stenosis in patients undergoing peripheral and coronary angiography. Int Urol Nephrol 2013; 45
Bageacu S, Cerisier A, Isaaz K, Nourissat A, Barral X, Favre JP. Incidental visceral and renal artery stenosis in patients undergoing coronary 2 angiography. Eur J Vasc Endovasc Surg 2011; 41
Przewłocki T, Kabłak-Ziembicka A, Tracz W, Kozanecki A, Kopeć G, Rubiś P, et al.
Renal artery stenosis in patients with coronary artery disease. Kardiol Pol 2008; 66
:856–862; discussion 863–864.
Park S, Jung JH, Seo HS, Ko YG, Choi D, Jang Y, et al.
The prevalence and clinical predictors of atherosclerotic renal artery stenosis in patients undergoing coronary angiography. Heart Vessels 2004; 19
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]