腎血管病的處理課件

ManagementofRenovascularHypertension

阜外心血管病醫(yī)院心內(nèi)科蔣雄京

InterrelationamongRenalArteryStenosis,Hypertension,andChronicRenalFailure

DefinitionofRenalArteryStenosis

Renalarterystenosis(RAS)isdefinedasnarrowingofthelumen

oftherenalartery.

*angiographicdiameterstenosis>50%

*translesionalpressuregradientof>20

mmHgpeaksystolic

or10mmHgmean

ThemostcommoncausesofRASareatherosclerosis(>80%),aortoarteritis(<15%),andfibromusculardysplasia(<5%)inChina

AngiographicAppearanceoftheThreeCommonFormsofRenalArteryStenosisPrevalence1.1~3%inhypertensivepopulation2.20~30%inpatientswithsecondaryhypertensionIncidenceofRenalArteryStenosis

atCardiacCatheterization

AuthorsYearCountryPatientsAgeCAD(%)HT(%)RAS(%)Crowley1998USA141526189726.3Conlon2000Ireland398752100586.3Weber2002Austriamashita2002Japan2896676487Rihal2002USA29765NA10019.2Buller2004Canada83767683214.3Addad2005Tunisia30058100359CAD=Coronaryarterydisease;HTN=Hypertension;RAS=significantrenalarterystenosis;NA=nonavailable.IncidenceofRenalArteryStenosisatCardiacCatheterization

inChinesepopulation

StudyAuthorsZhangetalPts,n

1200RAS>50%9.7Bilateral,%1.7IndicationSuspectedCHDWangetal23014.8NRCHDShenetal28015.35.0SuspectedCHDLiuetal14118.4NRSuspectedCHDMean185111.8NRProgressiveAtherosclerosis,RenalArteryStenosis,andIschemicNephropathy

theclinicalmanifestationsofARVDClinicalfeaturessuggestiveofrenovascularhypertension

JNC-VI

Onsetofhypertensionaged<30y;Abdominalbruit;Acceleratedorresistanthypertension;Flashpulmonaryedemawithnormalleftventricularfunction;Renalfailureofuncertaincause;Coexisting,diffuseatheroscleroticvasculardiseaseAcuterenalfailureprecipitatebyantihypertensivetherapy,particularlyACEIorAIIreceptorblockers;InthepresenceoftheseclinicalcluestheprevalenceofRVHis<40%.ScreeningforRenovascularHypertension1.Radionucliderenalfractionalflow/GFR2.Plasmareninactivity3.Captoprilrenoscitigraphy4.Colordopplorultrasonography5.MRAngiography/CTAngiographyMulti-slicesCTAismostusefulforRASscreeningSeverityofrenalvasculardiseasepredictsmortalityinpatientsundergoingcoronaryangiographyKidneyInternational(2001)60,1490–1497

ClinicalCriteriaforRevascularizationHypertension:acceleratedhypertension;refractoryhypertension;malignanthypertension;hypertensionwithaunilateralsmallkidney;or

hypertensionwithintolerancetomedication.

Renalsalvage:

suddenunexplainedworseningofrenalfunction;

impairment

ofrenalfunctionsecondarytoantihypertensivetreatment,

particularly

withanangiotensin-convertingenzymeinhibitor

orangiotensin

IIreceptorblocker;orrenaldysfunction

notattributable

toanothercause.

Cardiacdisturbancesyndromes:recurrent

"flash"pulmonaryedema

outofproportiontoanyimpairment

ofleftventricularfunction,orunstableangina

inthesettingofsignificantRAS.MedicalTherapy

controlofbloodpressure:ACEinhibitorsorAngiotensinreceptorblockers?antiplatelettherapysmokingcessationaggressivecontrolofhyperlipidemiaandDMThebestmedicaltherapyforARVDremainsunclear.MedicaltherapyhardlypreventsrenalfunctionworseninpatientswithbilateralRASorRASofsinglekidney.

ChabovaV,etal.

MayoClinProc2000;75:437-444BaboolalK

AmJKidneyDis1998;31:971-977腎動脈支架置入meta-analysisdatademonstratingsuperiorityofrenalarterystentcomparedwithballoonangioplastyforproceduresuccessandrestenosisrates

阿斯匹林0.1~0.3QD,氯吡格雷75mgQD，2-3天;降壓,血壓控制在<160/100mmHg；碘過敏試驗;EndovascularTreatmentofRenalArteryStenoses1.ThroughafemoralaccessEmerald.035.014Stabilizer+6FBriteTipSheath55cmEndovascularTreatmentofRenalArteryStenoses2.ThroughabrachialaccessTempo4FMP+.014StabilizerRenalArteryStentingCasereport-1女，60歲，發(fā)現(xiàn)高血壓2年，最高200/120mmHg。反復(fù)出現(xiàn)胸悶，夜間陣發(fā)性呼吸困難，不能平臥，雙下肢浮腫。二型糖尿病10年。用藥：蒙諾10mgQd，波依定5mgQd，壽比山2.5mgQd，血壓一般控制在150/90mmHg左右。血肌酐244umol/L,尿素氮22.9mmol/L,K+5.76mmol/L,GLU8.09mmol/L，尿〔-〕胸片示雙肺淤血，右側(cè)少量胸腔積液，UCG示左房前后徑45mm，左室舒張末期前后徑61mm，EF43%冠脈造影〔-〕MRA雙腎動脈近段重度狹窄〔>90%〕腎γ照相〔99mTc-DTPA〕ARVD–RandomizedStudiesPTRAvsMedication腎動脈支架的臨床結(jié)果

文獻匯總分析：腎功能：

1/3提高1/3不變1/3惡化高血壓：

治愈改善FMD50–85%85-100%ARAS5–15%50–70%TA40-60%75-90%ASTRALAngioplastyandSTentforRenalArteryLesionsUKMULTI-CENTRETRIALIN

ATHEROSCLEROTICRENOVASCULARDISEASEPhilipAKalraLeadNephrologistforASTRAL,HopeHospital,Salford,UK,OnbehalfoftheASTRALTMCandcollaboratorsASTRALTrial:

Design806403MedicalRx

403StentAssigned308Stent(76%)44NotAttempted17Failed34NotKnownPrimaryandsecondaryendpointsinASTRAL

Primaryendpoint

Secondaryendpoints

BloodpressurecontrolRenalevents(suchasacuterenalfailure,dialysis,transplantornephrectomy)Seriousvascularevents(suchasmyocardialinfarction,anginaorstroke)MortalityRateofprogressionofrenaldysfunction(usingserumcreatinineanalysedbyreciprocalcreatinineplotsovertime)

StentMedRxpValueAge7071NSMale63%63%NSDiabetes31%29%NSCr179178NSGFR4039NSBilateral50%50%NSACE/ARB47%38%NSBaselineCharacteristics

ASTRAL:LesionSeverityMean=76%(Range:20%–100%)Sitereported:nocorelabNo.ofpatientsStenosis(%)ASTRAL:

TreatmentRevascularizationStrategies:?Stenting93%?PTAalone7%?Post-stentresidualstenosis>50%:

12%?Complications:7%–Perforations:4(1%)–CholesterolEmboli3(1%)–Death<30daysofstent:2(0.5%)ASTRAL:

PrimaryEndpoint,1/Cr7.507.006.506.005.505.000612182430364248RevascularisationMedicalManagementMonthsfromRandomisation4033393202842201328440334832829921513077RevascularisationMedicalP=nsASTRAL:

ChangeinSystolicBPP=ns1050-5-10-15-2010730-3-7-10612182430364248612182430364248MonthsfromRandomisationRevascularisationMedicalManagementMeanChangeinSystolicBPTreatmentDifferenceRevascularisation:38433031527421613783Medical:38834132729021112781ASTRALEventComposite:

MI,StrokeVascularDeathHospitalizationforAngina,FluidOverloadorCHF以前的RCT研究ASTRAL

經(jīng)皮腎動脈成形聯(lián)合藥物治療優(yōu)于單純藥物治療未能證明支架+藥物治療藥物治療EffectivenessofManagementStrategiesforRenalArteryStenosis質(zhì)疑-1806403MedicalRx

403StentAssigned308Stent(76%)44NotAttempted17Failed34NotKnown質(zhì)疑-2入選標(biāo)準(zhǔn)太寬，大局部病例的腎動脈狹窄不能肯定是否有功能意義.

ASTRALTrial:Design1)with≥1ARVDlesion,and2)inwhom“substantialuncertaintyaboutwhetherearlyrevascularizationisclinicallyindicated.Inparticularitshouldbeunlikelythatrevascularizationwillbecomedefinitelyindicatedwithinthenext6months.〞ASTRAL:LesionSeverityMean=76%(Range:20%–100%)Sitereported:nocorelabNo.ofpatientsStenosis(%)?MedicaltherapyAssociatedwithprogressivedeclineinrenalfunction?StentingBeneficialeffectonslopeof1/Cr“Stabilization〞ChabovaMayoClinProc2000;75:437-44.HardenLancet1997;349:1133-1136.WatsonCirc2000;102:1671-7.76543210-600-500-400-300-200-1000100200300400500600SerumcreatinineX10-3藥物治療與介入治療的隨機比照研究

可靠嗎？最大問題是方法學(xué)上的可比性差：藥物治療組在不同中心的質(zhì)控可保持根本一致，但介入治療組由于不同中心的研究團隊水平差異，質(zhì)控很難保持一致，對結(jié)果影響很大.ASTRAL等隨機臨床研究的啟示

經(jīng)皮支架重建血運治療粥樣硬化性腎動脈狹窄的中遠期臨床結(jié)果

中國醫(yī)學(xué)科學(xué)院北京協(xié)和醫(yī)學(xué)院阜外心血管病醫(yī)院

蔣雄京楊倩楊躍進吳海英張慧敏惠汝太高潤霖有效？無效？本研究報告我院近5年來連續(xù)238例ARAS患者經(jīng)皮支架置入重建腎動脈血運的中遠期臨床結(jié)果，對該問題作一探討。資料與方法本研究病例入選標(biāo)準(zhǔn)：(1)腎動脈主干或主要分支直徑狹窄≥60%，如直徑狹窄僅為60%~75%，那么必須具備狹窄遠、近端壓差≥30mmHg或卡托普利腎圖陽性(2)未服降壓藥時血壓>180/110mmHg或正規(guī)三聯(lián)降壓藥治療血壓>140/90mmHg；(3)血肌酐<264μmol/L；(4)患腎長度>7.0cm，并且剩余的GFR>10ml/min；(5)年齡≥30歲，性別不限。排除標(biāo)準(zhǔn)：(1)病情不穩(wěn)定，無法耐受介入治療；(2)造影劑過敏；(3)腎動脈病變的解剖條件不適合進行介入治療結(jié)果-患者的根本臨床特征患者(n=238)的基線臨床特征年齡(歲)33～83(64.2±9.5)男性,例(%)178(74.8)糖尿病,例(%)62(26.1)高脂血癥,例(%)136(57.1)吸煙(目前或曾經(jīng)),例(%)141(59.2)合并其他外周血管疾病,例(%)105(44.1)術(shù)前蛋白尿,例(%)20(8.4)腦卒中或短暫腦缺血發(fā)作史,例(%)45(18.9)冠心病,例(%)156(65.5)心肌梗死史,例(%)53(22.3)瓣膜性心臟病,例(%)12(5.0)嚴(yán)重慢性心衰(NYHAⅢ～Ⅳ級),例(%)17(7.1)結(jié)果-患者的根本臨床特征患者(n=238)的基線臨床特征(續(xù))高血壓病史(月)1～600(159.5±143.9)收縮壓(mmHg)161.6±22.2舒張壓(mmHg)94.6±8.8服用降壓藥種類數(shù)(種)1～5(2.9±1.6)狹窄程度(%)60～100(82.9±8.1)單側(cè)腎動脈狹窄,例(%)172(72.3)雙側(cè)腎動脈狹窄,例(%)66(27.7)開口和(或)近端狹窄,條(%)292(95.4)中遠端狹窄,條(%)14(4.6)術(shù)前管腔直徑(mm)0～2.45(1.0±0.5)血肌酐水平(umol/L)44.0～263.92(108.9±42.3)

血肌酐＜133umol/L,例(%)202(84.9)

血肌酐133～177umol/L,例(%)26(10.9)

血肌酐＞177umol/L,例(%)10(4.2)血尿素水平(mmol/L)

2.9～23.8(7.5±3.3)PTRAS的造影和支架結(jié)果及并發(fā)癥

并發(fā)癥轉(zhuǎn)歸股動脈穿刺點大血腫2例，出血1例均經(jīng)輸血和延長加壓包扎后治愈股動脈穿刺點假性動脈瘤形成1例經(jīng)外科手術(shù)修補后治愈急性腎功能不全3例(2例夾層)1例2周后恢復(fù)至術(shù)前水平，1例持續(xù)惡化，1例術(shù)后第6日心源性猝死1例的1條分支血管被支架壓閉腎功能未受影響手術(shù)側(cè)腎囊血腫伴血色素進行性下降2例考慮系腎動脈穿孔所致，經(jīng)輸血后好轉(zhuǎn)，隨訪觀測基本吸收腦卒中3例缺血性2例，1例無后遺癥，1例有后遺癥，出血性1例，術(shù)后第3日死亡結(jié)果-隨訪及失訪情況

隨訪時間(月)61218243036424854606672應(yīng)有人數(shù)(例)238225193159134112967563453726實際隨訪到的總?cè)藬?shù)(例)228219192158131111967463453726失訪人數(shù)(例)1061131010000死亡人數(shù)(例)740101101000實際隨訪到的存活人數(shù)(例)22120818114611998826048302211

隨訪6～72(29.2±19.6)個月，共失訪23例(9.7%)PTRAS對血壓的影響臨床判定的支架內(nèi)再狹窄率3.0%(7/238)PTRAS對腎功能的影響PTRAS后血壓和腎功能轉(zhuǎn)歸

術(shù)后6、12個月時患者的血壓和腎功能轉(zhuǎn)歸(例)觀察時間例數(shù)血壓

肌酐治愈改善無效

改善無變化惡化術(shù)后6個月221(100)3(1.4)184(83.2)34(15.4)71(32.1)133(60.2)17(7.7)術(shù)后12個月208(100)5(2.4)176(84.6)27(13.0)

65(31.3)122(58.7)21(10.0)本研究PTRAS后的無事件生存率SeverityofrenalvasculardiseasepredictsmortalityinpatientsundergoingCAGKidneyInternational(2001)60,1490–1497PTRAS后的心血管事件共發(fā)生心血管事件24例(10.1%)，另有其他原因死亡4例。心血管事件例數(shù)腎臟事件5例(2.1%)急性心肌梗死4例(1.7%)腦卒中4例(1.7%)心腦血管死亡11例(4.6%)

隨訪期患者發(fā)生各種心血管事件的相關(guān)因素

事件相關(guān)因素優(yōu)勢比(95%CI)P心腦血管死亡術(shù)后12個月高血壓治愈或改善0.070(0.011-0.453)0.008術(shù)后12個月腎功能改善或穩(wěn)定0.090(0.016-0.476)0.009總死亡術(shù)后12個月高血壓治愈或改善0.002(0.000-0.151)0.005術(shù)后12個月腎功能改善或穩(wěn)定0.013(0.000-0.785)0.038年齡1.640(1.071-2.513)0.023術(shù)前基線收縮壓值1.067(1.002-1.137)0.044腎臟事件術(shù)后12個月腎功能改善或穩(wěn)定0.009(0.000-0.524)0.025術(shù)前基線尿素氮值1.409(1.049-2.157)0.03所有心血管事件術(shù)后12個月高血壓治愈或改善0.098(0.019-0.499)0.005術(shù)后12個月腎功能改善或穩(wěn)定0.134(0.035-0.509)0.003術(shù)前基線收縮壓值1.032(1.005-1.059)0.019Case1:Bilateralrenalarterystenosesinaaged69elderlywithrenalinsufficiency,3antihypertensivemedications,BP178/88mmHg,Cr187umol/l

Follow-upOneantihypertensivedrug3daysBP134/82mmHg,Cr132umol/l14daysBP132/84mmHg,Cr118umol/l6monsBP128/72mmHg,cr107umol/l12monsBP126/76mmHg,cr112umol/lMale,61yr，Hypertension>10yr，BP180/110mmHgwithfiveantihypertensivemedications.CHD,2yearsagoLADPCI,Smoking,HyperlipidimiaSCr205umol/l3daysafterprocedureBP132/84mmHgwithtwoantihypertensivemedicationsSCr128umol/l24monthsafterprocedureBP124/7284mmHgwithtwoantihypertensivemedicationsSCr116umol/l64-slicesCTAfindingonafemale,65yo.Highbloodpressure20years,MaximalBP210/120mmHG,outofcontrolwithnifedipineIGTS30mgqd,bisoprolol5mgqd,andperindopril4mgqd,for5years,Exacerbate3m

結(jié)論阜外醫(yī)院腎動脈狹窄研究的現(xiàn)狀1999-至今已積累550例腎動脈介入病例。近年來新來我院診治的腎動脈狹窄患者300例/年以上，實施介入治療病例>150例/年，歐美國家到達如此規(guī)模的醫(yī)學(xué)中心不到5家。腎動脈介入治療的現(xiàn)狀技術(shù)成功率有效率并發(fā)癥圍手術(shù)期死亡率阜外醫(yī)院99%86.7%3.6%0.4%國際文獻95~100%50~76%4~15%0.3~1%

以腎功能不全的進展率為主要終點事件的研究，如果要取得陽性結(jié)果，那么需要滿足二個關(guān)鍵點：1.病例入選要嚴(yán)格，即雙側(cè)或單功能腎的腎動脈嚴(yán)重狹窄〔>70%〕所致的缺血性腎病。對于單側(cè)腎動脈狹窄,患腎較對照側(cè)腎功能下降至少>25%。2.從事腎動脈介入的治療團隊富有經(jīng)驗，能有效防范介入對腎臟直接損害。1.介入操作過程中發(fā)生的腎動脈栓塞及其它損傷；2.造影劑誘發(fā)的腎毒性；3.血容量缺乏導(dǎo)致的腎灌注缺乏。重視控制危險因素纖維肌性結(jié)構(gòu)不良(FMD)及大動脈炎所致的腎動脈狹窄

ClinicaloutcomesofPTRAasTreatmentforRenalArteryStenosiscausedbyaortoarteritisorFMDJiangXiongjing,etal.

HypertensionDivision,CardiovascularInstituteandFuWaiHospital,CAMSandPUMCMETHOD

PatientsselectionforPTRAInpresenceofrenalartery>60%diameterstenosis,PatientshadPoorlycontrolledhypertensionwhilereceiving3antihypertensivemedicationsorHBPgradeIIIwithoutantihypertensivemedications.a.Increasedrenalveinreninb.CaptoprilRenoscitigraphyPositivec.serumcreatininelevel<264umol/L(3.0mg/dl)d.StentingIncaseof>30%residualstenosisafterPTAe.Longitudinalkidneylength>7.0cmwithGFR>10ml/minIndicationsforinclusionwerenotmutuallyexclusive.Clinicalcharacteristicsof80studypatientsGENDER(m/f)28/52AGE(YR)13~58(2914)

ETIOLOGY(N)

FIBROMUSCULARDYSPLASIA18(22.5%)ARTERITIS62(77.5%)Lesionsstenoses(%)60%~100%(8215)

Bloodpressureresponse(SBP/DBP,mmHg)

afterPTRA

baselinedischarge6monthArteritis174.5±32.8/106.8±20.4129.2±21.6/80.2±11.5*134.6±25.3/83.4±13.6*#FMD156.4±26.8/104.6±12.4126.4±15.2/75.6±9.8*128.8±17.6/76.2±10.4*

No.ofmed2.9±1.31.0±1.1*1.2±1.4*#

*P<0.001comparedwithbaseline.#P<0.05comparedwithvaluesatdischarge.SBP=systolicbloodpressure;DBP=diastolicbloodpressureTheeffectofPTRAonhypertensionat6-monthfollow-up

EtiologyCure(%)Improved(%)N