Renal Artery Stenosis in Patients with Established Coronary Artery Disease: Prevalence and Predicting Factors : Saudi Journal of Kidney Diseases and Transplantation

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Original Article

Renal Artery Stenosis in Patients with Established Coronary Artery Disease: Prevalence and Predicting Factors

Khatami, Mohammad Reza1; Edalati-Fard, Maryam2; Sadeghian, Saeid3; Salari-Far, Mojtaba3; Bs, Mina Pashang3

Author Information

1Nephrology Research Center, Tehran University of Medical Sciences, Tehran, Iran

2Imam Khomeini Hospital, Tehran, Iran

3Tehran Heart Center, Tehran, Iran

Address for correspondence: Dr. Mohammad Reza Khatami, Nephrology Research Center, Tehran University of Medical Sciences, Tehran, Iran. E-mail: [email protected]

Saudi Journal of Kidney Diseases and Transplantation 25(5):p 986-991, September 2014. | DOI: 10.4103/1319-2442.139880
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Abstract

 

The association between renal artery stenosis (RAS) and other atherosclerotic diseases (particularly coronary artery diseases) is well known. In general, the risk factors for atherosclerosis have been clarified, but whether these risk factors operate equally in all forms of atherosclerotic diseases is not known. The aim of this study was to describe the prevalence of RAS in patients with established coronary artery diseases and then to define the most important risk factors that may help to predict the RAS in this population. In this cross-sectional study, 146 patients with established coronary artery stenosis by angiography simultaneously underwent renal angiography; RAS >50% was considered significant. We found that 25.3% of patients with coronary artery diseases had RAS. The prevalence of significant stenosis was 17.1%. Females were more vulnerable to this disorder than males (47.1% vs. 13.7%, P = 0.001). There was no relationship between the severity and number of stenosed coronary arteries and those of stenosed renal arteries (P = 0.716). Multi-variate logistic regression analysis revealed that among the risk factors for atherosclerosis, female sex (P = 0.001), duration of hypertension (P = 0.032), age (P = 0.046) and serum creatinine (P = 0.018) were strong predictors of the presence of RAS. We concluded that RAS is a common finding in patients with coronary artery disease. We suggest that all older females with deteriorating renal function and long-standing hypertension should be carefully evaluated for early detection of the RAS.

Introduction

Renal artery stenosis (RAS) is the cause of ischemic nephropathy and is an important cause of secondary hypertension. Since the early 1980s, the association of chronic kidney di-sease (CKD) and RAS has been clearly shown, and the pathogenetic role of RAS in the development of hypertension and ischemic nephropathy have been defined.1

Patients with end-stage renal disease (ESRD) who are on dialysis due to RAS have signi-ficantly poorer survival than patients dialyzed due to other causes. About 2% of such patients die annually, and the mean survival and percentage of patients alive at five years are 27 months and 12%, respectively. The prevalence of RAS in hypertensive patients is reported to be 1-10% and the prevalence of end-stage renal disease (ESRD) due to RAS has increased from 6-7% in 1978-1981 to 16.5% in 1982- 1985.23 Overall, RAS is the cause of ESRD in 10-20% of patients aged above 50 years.4

The "gold standard" method for diagnosing RAS is renal angiography, which is an inva-sive technique with known complications and, therefore, it should be performed if a high probability of stenosis is suspected. Many investigators investigated the criteria to detect patients at high risk for RAS.567

A strong correlation has been shown between coronary artery disease (CAD) and RAS.8 Yorgun and his colleagues reported that the only independent predictor factor of RAS is CAD.9 Some authors studied the risk factors for atherosclerotic renovascular diseases and their association with RAS.101112 The results of these studies is controversial and different risk factors have different roles in the evolution of atherosclerotic disorders.

The aim of our study was to determine the risk factors that strongly predict the presence of significant RAS in our CAD patients.

Materials and Methods

The study protocol was approved by the Ethics Committee of the Research Department of the Tehran University of Medical Sciences. All the patients signed a written consent form that was approved by the ethics committee.

We studied in a cross-sectional model 173 adult patients who underwent coronary angio-graphy; 146 patients had significant coronary artery stenosis (>50%). Renal angiography was simultaneously performed in these patients. All angiographic data were reviewed by two expert cardiologists to define the RAS seve-rity. Patients with any degree of stenosis were considered to have RAS. However, "signi-ficant RAS" was defined as ≥50% stenosis. The correlation between RAS and sex, age, diabetes mellitus (DM), hypertension, smoking, body mass index (BMI), serum creatinine le-vel and lipid profile were evaluated.

Before angiography, all data of the patients were collected and necessary laboratory tests were completed.

Statistical Analysis

We used the software STATA version 9.1 (STATA, College Station, TX, USA) for sta-tistical analysis in this study. Qualitative and quantitative data were presented as percen-tages and mean ± standard deviation (SD), respectively. The chi-square test or Fisher’s test was selected to compare quantitative determinants and the Student’s two-tailed t-test was used for qualitative data. Multivariate logistic regression analysis was used to show the effect of factors. P <0.05 was considered as significant.

Results

Table 1 shows the demographic data and the clinical characteristics of the patients. The total prevalence of RAS was 25.3%, whereas significant RAS (>50% stenosis) was observed in 17% of patients; 6.2% of patients had bilateral RAS. We did not find differences between males and females (P = 0.229 and P = 0.716, respectively) regarding the correlation between the severity of stenosis and the location of RAS. The age and BMI of both groups were similar, but hypertension and DM were signi-ficantly more prevalent in females. The dura-tion of hypertension was also longer in females with RAS.

T1-6
Table 1:
Characteristic data of patients undergoing renal angiography

Table 2 shows the characteristics of patients with significant RAS. The prevalence of significant RAS was higher in females than in males (47.1% vs. 13.7%; P = 0.001). Patients with significant RAS were also older than patients with normal renal arteries (P <0.001). A history of hypertension and DM was more prevalent in patients with significant RAS (P = 0.006 and P = 0.004, respectively). The dura-tion of hypertension and DM was also longer in these patients (P = 0.006 and P = 0.001, res-pectively). There were no significant diffe-rences between males and females with respect to hyperlipidemia and smoking. Regarding CAD, 30 patients (13%) had minimal CAD, 26 patients (18%) had single CAD, 44 patients (30%) had two-vessel disease and 57 patients (39%) had three-vessel disease. No relationship was found between the number of stenotic coronary arteries or their severity and those of the renal arteries (P = 0.763 and P = 0.473, respectively).

T2-6
Table 2:
Characteristic data of patients with and without significant RAS

Table 3 shows the multivariate logistic regression analysis of the risk factors of athe-rosclerosis and RAS. Female sex was a strong predictor of RAS (P = 0.001). Older age (P = 0.046) and serum creatinine (P = 0.018) had a good correlation with RAS. The probability of RAS occurrence increased in patients with a longer duration of hypertension (P = 0.032), but DM failed to show this correlation (P = 0.157). None of the patients had contrast nephropathy.

T3-6
Table 3:
Multivariate regression logistic analysis to determine the predictive factors for detecting renal artery stenosis in angiography

Discussion

RAS is a common finding in atherosclerotic patients. It is a progressive disorder and total occlusion of arteries occurs in many of these patients.1314151617 This is associated with a signi-ficant increase in morbidity and mortality in 1-2 years.1819 It has been shown that the pre-valence of lesion progression, renal atrophy and renal artery occlusion were approximately 20%, 10% and 5% per year, respectively.20

The prevalence of RAS and its association with other atherosclerotic disorders have been shown in several studies. Apple et al21 summarized seven studies published between 1964 and 1994 about the prevalence of renal artery diseases. This review showed that the prevalence of RAS in non-dialysis patients was 7-50%. This wide range of prevalence was due to the different health status of the patients (including comorbidity). The prevalence of RAS in patients with CAD and renal insuf-ficiency was 25%, whereas it was around 19% in patients with CAD who were not suffering from renal insufficiency.

Recently, researchers have focused on scree-ning for RAS by renal angiography during coronary angiography.22 There is no evidence-based guideline to indicate which patients should undergo renal angiography during coronary angiography.2324 In one study, it has been shown that 60% of patients with peri-pheral atherosclerosis and <30% of patients with coronary artery stenosis have RAS.25 Yuqiang et al showed that there was a 10.9% coexistent rate between coronary artery ste-nosis and RAS.26 Alhaddad et al27 showed that in patients with CAD, age and serum creatinine were important risk factors for predic-ting RAS. However, they found that sex and blood pressure were not important predictors of RAS. The total prevalence of RAS in that study was 13.5%, but significant RAS was found only in 7.7% of patients. Aqel et al28 showed that other than age and renal function, peripheral vascular disease (but not CAD) was a predictive factor for RAS. A total of 28% and 16% of their patients had RAS with ste-nosis >50% and >75%, respectively. Buller et al29 showed that 14.3% of patients had >50% RAS and 7.3% of patients had >75% stenosis. They also reported that age, blood pressure, peripheral vascular disease, serum creatinine and female sex were important risk factors of RAS. Cohen et al30 also reported that females were more vulnerable to RAS. The prevalence of RAS more than 70% stenosis was 17% in this study. Crowley et al31 believed that cerebrovascular diseases were important for predicting RAS. In their study, RAS was found in 6.3% of patients. Harding et al32 reported that besides age, female sex and peripheral vascular diseases, CAD severity rather than the number of coronary arteries involved were risk factors for RAS. The prevalence of overall and significant RAS was reported to be 30% and 11%, respectively. Jean et al8 showed that 92% of CAD patients had RAS, but only 7% of RAS patients had CAD. They concluded that only CAD and renal function were predictive factors for RAS. Landri et al33 stated that patients with increased serum creatinine and coronary artery involvement were more likely to have RAS, but without these two factors only 5.2% of patients had RAS. Oliver et al34 showed that, in contrast to many other studies, male sex was a risk factor of RAS. They reported that 14.2% of patients had RAS.

In the present study, 25.3% of patients had RAS and 17.1% had significant RAS. These values were higher than many other studies. In our study, 6.2% of patients had bilateral RAS; this was more prevalent than other studies.

Our present study demonstrated that females were more likely to be affected by RAS. Even after omitting the confounding factors, this effect was significant. In contrast with many other communities in Iran, female sex is known to be an important risk factor for cardio-vascular disease.35 It is therefore unsurprising to see a higher prevalence of RAS in females than in males. The present study also showed that the risk factors of atherosclerosis (e.g., hypertension, DM, hyperlipidemia) were more prevalent in females.

Another important result of the present study was the good correlation between the duration of hypertension and evolution of RAS. Studies have shown that 13-50% of patients with hypertension and cardiovascular diseases have RAS832 and that if renal failure is added, the prevalence of RAS increases to 60%.363738 One explanation for the relationship between RAS and the duration of hypertension is that, like many other countries, hypertensive patients in Iran do not have good control of blood pres-sure (although they might be more vulnerable to the side-effects of uncontrolled hypertension, including progressive atherosclerosis). Aqel et al28 did not show a relationship between RAS and control of blood pressure, but the number of related studies is limited. More studies are needed to reveal this relationship.

In contrast to the study by Dzielinska and coworkers,1011 we did not find a significant correlation between the number and severity of the involved coronary arteries and RAS. How-ever, the risk factors for CAD (e.g., sex, hyper-tension) play an important part in RAS; there-fore, CAD should be considered to be a risk factor for RAS per se. Like Dzielinska and coworkers, Brent et al also recommended that patients with hypertension and multi-vessel CAD are good candidates for renal artery angiography.12 They showed that increased carotid intima-media thickness is associated with an increased prevalence of RAS. In accor-dance with many studies (including the present study), they found a good correlation between even moderate renal impairment and RAS in patients undergoing coronary angiography.

The most important limitation of our study was the short-term follow-up of patients. It seems necessary to ascertain whether the risk factors for the evolution of RAS have a role in the progression of stenosis. The other limi-tation was the selection of patients with con-firmed CAD. We could not discuss the preva-lence of overall RAS in patients with risk factors for atherosclerosis.

We conclude that the present study showed that RAS is a common finding in patients with CAD. The prevalence of RAS was increased in females suffering from long-term hyper-tension and CKD. Accordingly, we believe that all females with a history of long-standing hypertension should be considered, if they have a plan for coronary angiography, for both coronary and renal artery angiography simul-taneously.

Conflict of Interest

The authors report no conflicts of interest. The authors alone are responsible for the con-tent and writing of the paper.

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