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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 3  |  Page : 875-881

Prevalence and predictors of renal artery stenosis in hypertensive patients undergoing coronary angiography


1 Department of Cardiovascular Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Cardiovascular Medicine, National Heart Institute, Giza, Egypt

Date of Submission10-Feb-2017
Date of Acceptance02-May-2017
Date of Web Publication31-Dec-2018

Correspondence Address:
Ashraf F Abd-Allah
Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_95_17

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  Abstract 


Objective
The aim of the study was to evaluate the prevalence and predictors of renal artery stenosis (RAS) in hypertensive patients undergoing elective coronary angiography.
Background
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.
Results
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.
Conclusion
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 May 24];31:875-81. Available from: http://www.mmj.eg.net/text.asp?2018/31/3/875/248772




  Introduction Top


Renal artery stenosis (RAS) is defined as narrowing of the renal artery lumen[1]. The most common etiology of RAS is atherosclerosis, which involves the main renal artery[2].

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[3],[4],[5],[6],[7]. In addition, RAS is the etiology for 20% of dialysis individuals who are older than 50 years[1].

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[2].

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[1]. 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[8]. Existence of ARAS worsens the CAD course and prognosis[2]. On the contrary, CAD is one of the most important reasons of death in patients with ARAS[9].

The prevalence of RAS in individuals with suspected CAD who underwent coronary angiography was reported from 11.3 to 39% by some studies[1]. Overall, 1–5% of individuals with blood HTN experience RAS, whereas it is the most common etiology of secondary HTN[2]. Owing to high coexistence of RAS and CAD in cases with angiography-diagnosed CAD[10], it has been advised that renal angiography be performed in conjunction with coronary angiography[9].

Therefore, in our study, we aimed to evaluate the prevalence and predictors of RAS in hypertensive patients undergoing elective coronary angiography.


  Patients and Methods Top


Study design

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.

Patients' population

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.

Catheterization procedure

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%.

Statistical analysis

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 Top


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].
Table 1: Characteristics of the study population: Categorical variables

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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.

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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.

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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].
Table 2: Characteristics of the study population: Numerical variables

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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

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Figure 3: Prevalence of relevant risk factors among patients with or without renal artery stenosis (RAS).

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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).

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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

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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

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Figure 5: Receiver-operating characteristic curve derived from the multivariable binary logistic regression model for determinants of renal artery stenosis.

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  Discussion Top


The reported prevalence of significant RAS (>50%) among patients undergoing coronary angiography ranges from 6.2% to as high as 28%[11],[12]. 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[13],[14].

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.[10], 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.[15], Shah et al.[16], Yamashita et al.[17], Rihal et al.[8], Dzielinska et al.[12], Yorgun et al.[18], and Payami et al.[19], 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.[20] 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.[21] and Bageacu et al.[22], 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.[18], Ollivier et al.[11], and Przewłocki et al.[23] 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.[9].

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.[14] and in contrast to results in different studies such as Park et al.[24] who revealed that CAD, renal insufficiency, age, and hypercholesterolemia were independent predictors for the presence of RAS, whereas Payami et al.[19] 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 Top


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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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