腎臓学と治療学ジャーナル

Critical Appraisal of the Major Randomized Controlled Trails on the Management of Atherosclerotic Renovascular Disease (ARVD)

Abstract

Rebeen R. Saeed*

Background: In this article, the author discusses critical appraisals of the major randomized controlled trials on the management of Atherosclerotic Renovascular Disease (ARVD). The article will also discuss the limitations of the published trials, while highlighting the crucial aspect of appropriate patient selection, the serious flaws noted, and the quality of the main studies. Also included are the six major randomized controlled trials that compared the difference between revascularization, either surgical or PTRA (Percutaneous Renal Angioplasty), with or without stent versus conservative management (medication).The author also discusses the recommended research for the management of atherosclerotic renovascular disease.

Methodology and search strategies to identify studies: A comprehensive search of PUBMED including Medical Subject Headings (MeSH) data base from 1990 to may 2012 and The Cochrane library was completed. Searching was only for relevant English papers related to the management of Atherosclerotic renovascular disease.. CASP questionnaire, Jadad scaling and (Oxford Centre for Evidence-based Medicine) levelling of evidence are used for the purpose of the critical appraisal.

Criteria for considering studies for this article: To be considered, clinical studies had to be randomized trials comparing intervention; balloon angioplasty or stenting or both or surgical revascularization versus medical treatment, or surgical versus balloon angioplasty with or without stenting in hypertensive patients who had atherosclerotic renal artery stenosis with a minimum of three months of follow up after treatment Only those studies included with adult patients (age >18 years) who had uncontrolled hypertension (diastolic blood pressure ≥ 95mmHg, treated or untreated) and moderate-to-severe (≥50%) unilateral or bilateral atherosclerotic renal artery stenosis. Studies which were not randomized or those related to fibromuscular dysplasia, meta-analysis, and diagnostic studies were excluded.

Objectives: Explaining a critical appraisal of six major randomized clinical trials which compared Revascularization (intervention) to medication (conservative treatment) which includes Angioplasty and Stenting for Renal Artery Lesions Trial (ASTRAL), Stent Placement in Patients With Atherosclerotic Renal Artery Stenosis and Impaired Renal Function Trial (STAR), Dutch Renal Artery Stenosis Intervention Cooperative (DRASTIC), Essai Multicentrique Medicaments vs. Angioplastie trial (EMMA), Scottish and Newcastle Renal Artery Stenosis Collaborative Group trial (SNRASCG), and Prospective randomized trial of operative vs. interventional treatment for renal artery ostial occlusive disease (RAOOD) trials. We also highlighted some points about the ongoing CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) trial.

Conclusions: Correction of Astherosclerotic Renal Artery Stenosis (ARAS), either by surgical revascularization or percutaneous methods, including stenting, has not been shown to be beneficial in treating Atherosclerotic RAS over conservative treatment, although some of the studies showed blood pressure control benefit in intervention groups like EMMA, SNRASCG and post hoc analysis of DRASTIC studies. Consequently, it seems reasonable to consider interventional procedures to correct Renal artery stenosis in patients who do not respond to medical therapy or with poorly-controlled or resistant hypertension; recurrent flash pulmonary edema; dialysis dependent renal failure resulting from atherosclerotic renal artery stenosis; chronic kidney disease and bilateral renal artery stenosis; or Renal artery stenosis to a solitary functioning kidney and waiting for the next available research with less flaws and biases.