LETTER
Futility of Imaging Atherosclerotic Renal Artery Stenosis? To the Editor: In their scholarly report on the American College of Radiology Appropriateness Criteria, Remer et al1 list various imaging procedures to detect atherosclerotic renal artery stenosis in patients with chronic kidney disease. In doing so, they quote a study indicating that 14% of patients aged more than 50 years have atherosclerotic renal artery stenosis.2 There is little doubt that atherosclerotic renal artery stenosis is common and that it can be detected by imaging. For decades, we have searched for atherosclerotic renal artery stenosis in patients with hypertension. However, we have learned recently that identification and treatment of this entity may be futile. The Angioplasty and Stenting for Renal Artery Lesions, STent placement and blood pressure and lipid-lowering for the prevention of progression of renal dysfunction caused by Atherosclerotic ostial stenosis of the Renal artery, and Cardiovascular Outcomes in Renal Atherosclerotic Lesions trials leave little room for debate—hypertensive patients who have moderate to severe atherosclerotic renal artery stenosis with or without chronic kidney disease stage 3 should receive medical therapy without revascularization, similar to patients with “essential” hypertension. In a meta-analysis of trials comparing revascularization with medical therapy, renal artery revascularization was not associated with a change in systolic blood pressure from baseline when compared with medical therapy or with a reduction in adverse cardiovascular or renal outcomes.3 Even among patients with > 80% stenosis, percutaneous intervention conferred no benefits (Cardiovascular Outcomes in Renal Atherosclerotic Lesions). If imaging is used in these settings, it merely adds cost and
Funding: None. Conflict of Interest: FHM is a consultant to or has advisory relationships with Daiichi-Sankyo, Pfizer, Abbott, Servier, Medtronic, and WebMD. Authorship: All authors had access to the data and played a role in writing this manuscript.
0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved.
potential risk without any likelihood of benefit. So-called renovascular hypertension may well be a disease of the past, except in its acute life-threatening form when bilateral atherosclerotic renal artery stenosis presents with flash pulmonary edema (Pickering syndrome).4 As Bettmann5 eloquently points out in the accompanying editorial, “in any medical decision-making, the risk-benefit ratio should be considered. If there is essentially no likelihood of direct benefit to the patient, any risk is unacceptable.” This may well be the case for imaging in atherosclerotic renal arterial disease. Franz H. Messerli, MDa,b Chirag Bavishi, MD, MPHc Adrian W. Messerli, MDd a
Mount Sinai Health Medical Center Icahn School of Medicine Division of Cardiology New York, NY b Department of Cardiology Bern University Hospital Bern, Switzerland c Mount Sinai St Luke’s-Roosevelt Hospital Icahn School of Medicine New York, NY d Gill Heart Institute University of Kentucky Lexington
http://dx.doi.org/10.1016/j.amjmed.2015.01.047
References 1. Remer EM, Papanicolaou N, Casalino DD, et al. ACR Appropriateness Criteria on renal failure. Am J Med. 2014;127:1041-1048.e1. 2. Scoble JE, Maher ER, Hamilton G, Dick R, Sweny P, Moorhead JF. Atherosclerotic renovascular disease causing renal impairmentea case for treatment. Clin Nephrol. 1989;31:119-122. 3. Bavry AA, Kapadia SR, Bhatt DL, Kumbhani DJ. Renal artery revascularization: Updated meta-analysis with the coral trial. JAMA Intern Med. 2014;174:1849-1851. 4. Messerli FH, Bangalore S, Makani H, et al. Flash pulmonary oedema and bilateral renal artery stenosis: the Pickering syndrome. Eur Heart J. 2011;32:2231-2235. 5. Bettmann MA. The importance and role of clinical imaging guidelines: the example of the ACR Appropriateness Criteria((r)) on renal failure. Am J Med. 2014;127:1029-1030.
Futility of Imaging Atherosclerotic Renal Artery Stenosis? To the Editor: In their scholarly report on the American College of Radiology Appropriateness Criteria, Remer et al1 list various imaging procedures to detect atherosclerotic renal artery stenosis in patients with chronic kidney disease. In doing so, they quote a study indicating that 14% of patients aged more than 50 years have atherosclerotic renal artery stenosis.2 There is little doubt that atherosclerotic renal artery stenosis is common and that it can be detected by imaging. For decades, we have searched for atherosclerotic renal artery stenosis in patients with hypertension. However, we have learned recently that identification and treatment of this entity may be futile. The Angioplasty and Stenting for Renal Artery Lesions, STent placement and blood pressure and lipid-lowering for the prevention of progression of renal dysfunction caused by Atherosclerotic ostial stenosis of the Renal artery, and Cardiovascular Outcomes in Renal Atherosclerotic Lesions trials leave little room for debate—hypertensive patients who have moderate to severe atherosclerotic renal artery stenosis with or without chronic kidney disease stage 3 should receive medical therapy without revascularization, similar to patients with “essential” hypertension. In a meta-analysis of trials comparing revascularization with medical therapy, renal artery revascularization was not associated with a change in systolic blood pressure from baseline when compared with medical therapy or with a reduction in adverse cardiovascular or renal outcomes.3 Even among patients with > 80% stenosis, percutaneous intervention conferred no benefits (Cardiovascular Outcomes in Renal Atherosclerotic Lesions). If imaging is used in these settings, it merely adds cost and
Funding: None. Conflict of Interest: FHM is a consultant to or has advisory relationships with Daiichi-Sankyo, Pfizer, Abbott, Servier, Medtronic, and WebMD. Authorship: All authors had access to the data and played a role in writing this manuscript.
0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved.
potential risk without any likelihood of benefit. So-called renovascular hypertension may well be a disease of the past, except in its acute life-threatening form when bilateral atherosclerotic renal artery stenosis presents with flash pulmonary edema (Pickering syndrome).4 As Bettmann5 eloquently points out in the accompanying editorial, “in any medical decision-making, the risk-benefit ratio should be considered. If there is essentially no likelihood of direct benefit to the patient, any risk is unacceptable.” This may well be the case for imaging in atherosclerotic renal arterial disease. Franz H. Messerli, MDa,b Chirag Bavishi, MD, MPHc Adrian W. Messerli, MDd a
Mount Sinai Health Medical Center Icahn School of Medicine Division of Cardiology New York, NY b Department of Cardiology Bern University Hospital Bern, Switzerland c Mount Sinai St Luke’s-Roosevelt Hospital Icahn School of Medicine New York, NY d Gill Heart Institute University of Kentucky Lexington
http://dx.doi.org/10.1016/j.amjmed.2015.01.047
References 1. Remer EM, Papanicolaou N, Casalino DD, et al. ACR Appropriateness Criteria on renal failure. Am J Med. 2014;127:1041-1048.e1. 2. Scoble JE, Maher ER, Hamilton G, Dick R, Sweny P, Moorhead JF. Atherosclerotic renovascular disease causing renal impairmentea case for treatment. Clin Nephrol. 1989;31:119-122. 3. Bavry AA, Kapadia SR, Bhatt DL, Kumbhani DJ. Renal artery revascularization: Updated meta-analysis with the coral trial. JAMA Intern Med. 2014;174:1849-1851. 4. Messerli FH, Bangalore S, Makani H, et al. Flash pulmonary oedema and bilateral renal artery stenosis: the Pickering syndrome. Eur Heart J. 2011;32:2231-2235. 5. Bettmann MA. The importance and role of clinical imaging guidelines: the example of the ACR Appropriateness Criteria((r)) on renal failure. Am J Med. 2014;127:1029-1030.
