Hari Mamtora

Risk of morbidity from renovascular disease in elderly patients with congestive cardiac failure

BACKGROUND Renovasular disease commonly affects elderly people. Elderly patients with heart failure are routinely treated with angiotensin-converting-enzyme (ACE) inhibitors, which may increase risk of renal dysfunction. We investigated the frequency of renovascular disease among elderly people with heart failure. METHODS From the local population of Salford, UK, we recruited 86 patients with heart failure with a mean age of 77.5 (SD 5.6) years, who were admitted as acute emergencies or who attended general medical clinics. We selected patients by intention to treat with ACE inhibitors. We used captopril renography to screen for renovascular disease. All patients with abnormal renograms underwent magnetic-resonance angiography of the renal arteries as well as 40% of patients with normal renograms as negative controls. FINDINGS Magnetic-resonance angiography showed severe renovascular disease (>50% renal-artery stenosis or occlusion) in 29 (34%) patients. Captopril renography had an estimated sensitivity of 78.8% (95% CI 72.7-97.8) and specificity of 94.3% (67.6-97.3) for detection of renovascular disease. The estimated positive predictive value of captopril renography was 89.7% and the negative predictive value was 87.5%. Patients with renovascular disease had worse renal function (mean creatinine 201 [SD 56] vs 136 [40] pmol/L, p<0.001), were older (mean age 80.7 [5.6] vs 76.8 [5.3] years, p<0.01), and were more likely than patients without renovascular disease to have peripheral arterial disease. INTERPRETATION Some elderly patients with occult renovascular disease on ACE inhibitors will be at risk of developing uraemia. Renal function should be closely monitored to detect any deterioration early.

Measurement of single kidney function using dynamic contrast-enhanced MRI: comparison of two models in human subjects.

To compare two methods for assessing the single kidney glomerular filtration rate (SK‐GFR) in humans using dynamic contrast‐enhanced (DCE)‐MRI.

The Effects of Statins on the Progression of Atherosclerotic Renovascular Disease

Background/Aims: The aim was to examine the influence of statin therapy on the natural history of atherosclerotic renal artery stenosis (RAS). Methods: Our hospital atherosclerotic renovascular disease (ARVD) database was analysed for patients who underwent repeat renal angiography during clinical follow-up. Patients with ≧1 RAS lesion and ≧4 months between baseline and repeat renal angiography were analysed. 79 patients were included. Baseline renal arterial anatomy was classified as normal, ≤50% RAS, >50% RAS or renal artery occlusion. Results: Mean follow-up time between angiograms was 27.8 ± 22.3 (4.0–101.9) months. Progression of RAS occurred in 28 (23%) vessels, regression in 14 (12%) and no significant change in 79 (65%). Multivariate regression analysis showed that baseline proteinuria >0.6 g/day increased the risk of progressive disease (relative risk, RR, 3.8; 95% confidence interval, CI, 1.2–12.1), treatment with statin reduced the risk of progression (RR 0.28; 95% CI 0.10–0.77). 14 renal arteries from 12 patients showed RAS regression with a greater proportion on statin [statin treatment 10 (83%) versus no statin treatment 2 (17%), p = 0.001]. Change in estimated glomerular filtration rate (eGFR) per year was not different between statin- and no-statin-treated groups. Conclusions: Progression or development of RAS was significantly less likely to occur with statin therapy. ΔeGFR did not correlate with progression of RAS, reflecting the importance of intrarenal injury in the aetiology of renal dysfunction. Our results suggest statin therapy can alter the natural history of ARVD.

The importance of associated extra-renal vascular disease on the outcome of patients with atherosclerotic renovascular disease

Atherosclerotic renovascular disease (ARVD) is a disease of ageing. It is usually a manifestation of widespread vascular disease and although it may be symptomless, many patients with ARVD present with the effects of extra-renal vascular disease, such as peripheral vascular (PVD), coronary heart (CHD) and cerebrovascular disease. ARVD is a common cause of hypertension and chronic renal failure (CRF), and it is one of the most common renal diagnoses in elderly patients accepted on to dialysis programmes with end-stage renal failure (ESRF). The cause of renal impairment in these patients is still a matter of debate. Patients with ARVD have a high mortality, especially those with renal failure. In this review we examine the relationships between ARVD and co-morbid extra-renal vascular disease, and the impact of these associated vascular pathologies upon renal functional and mortality outcomes is considered. The latest evidence concerning the likely pathogenesis of renal dysfunction in patients with ARVD is also reviewed.