Transcript 報告者：fellow 1 陳筱惠 指導醫師：陳冠興醫師 Commented by CV1 張其任醫師

報告者：fellow 1 陳筱惠
指導醫師：陳冠興醫師
Commented by CV1 張其任醫師
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Name: 張O嗣
Sex: female
Age: 90-year-old
Chart number: 487733
Date of admission: 2011/11/18
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Persistent dizziness for 1 day
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Underlying diseases: chronic kidney disease
(stage 4), congestive heart failure, and atrial
fibrillation
Dizziness with bradycardia episode at home
(HR around 40bpm)
Associated S/S: no palpitation, chest pain,
cold sweating, or consciousness disturbance
At ER: clear consiousness, af SVR
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Hypertension (BP when OPD follow-up:
180~/70~mmHg)
Heart failure, LVEF:68%, HCVD related,
atrial fibrillation rhythm
Chronic kidney disease, stage 4, eGFR:
29.4ml/min, 2011/04/24 crea: 1.64mg/dl
Obstrutive sleep apnea syndrome with
restrictive lung
Asthma history
Other significant systemic diseases: denied
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Doxazosin 4mg 1# bid
Isosorbide-5-mononitrate cr 60mg 1# qd
Furosemide 40ng 0.5# qd
Aliskiren 150mg 1# qd 2011/06/28~
Exforge (Amlodipine 5mg + Valsartan 80mg)
1# bid 2011/11/15~
◦ Micardis Plus (Telmisartan 40mg + HCTZ 12.5mg)
1# qd 2011/10/18~2011/11/15
◦ Telmisartan 40mg
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Allergy: no known allergy
Alcohol: denied; betel-nut: denied; cigarette:
denied
Over-the-counter medication or chinese herb:
nil
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No family history of malignancy,
bleeding diathesis, heart, liver, kidney,
or hereditary diseases
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Vital signs: blood pressure: 135/58mmHg; temperature:
36.5‘C; pulse rate: 44/min; respiratory rate: 18/min
General appearance: acute ill looking
Eye: conjunctiva: pale, sclera: no icteric
Neck: supple, no lymphadenopathy or jugular vein
engorgement
Chest: symmetric expansion
breathing sound: bilateral clear
heart sound: irregular heart beats, no S3 or S4, no
murmurs
Abdomen: soft, flat, no tenderness, muscle guarding, or
rebounding
liver/spleen: impalpable
bowel sound: normoactive
Extremities: no lower limb pitting edema
Skin: intact, no rash
WBC
6.2x1000/ul
BUN
118.1 mg/dL
Hgb
8.3 g/dl
Creatinine
4.43 mg/dl
Hct
25.4 %
GPT
9 IU/L
MCV
87 fL
Na
134 mEq/L
PLT
159 x1000/uL
K
8.2 mEq/L
Ca
8.2 mg/dL
Mg
2.3 mEq/L
Tropo - I
<0.01 ng/mL
Segment
78.9 %
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Atrial fibrillation with slow ventricular rate,
suspect hyperkalemia induced
Acute on chronic kidney disease, favor ARB
drug effect, complicated with hyperkalemia
and azotemia
Hypertension, poorly controlled
Heart failure, LVEF:68%, HCVD related, atrial
fibrillation rhythm
Obstrutive sleep apnea syndrome with
restrictive lung
Asthma history
189/88
mmHg
141/72
mmHg
149/70
mmHg
165/79
mmHg
H/D
U/O
2020
660
740
860
BW
55.46
54.8
55.9
56.6
BUN
118.1
58.8
Crea
4.43
2.65
Na
134
138
K
8.5
5.1
Ca
P
C02
21.3
190/99
mmHg
159/72
mmHg
186/84
mmHg
206/94
mmHg
186/89
mmHg
2450
350
920
69.5
59.1
58.3
Kidney echo
U/O
230
1630
BW
BUN
68.7
73
Crea
2.82
2.45
Na
125
123
K
4.7
5.0
Ca
8.3
8.0
P
4.8
4.5
C02
201/96
mmHg
181/80
mmHg
145/66
mmHg
179/86
mmHg
156/72
mmHg
Cortisol 14.1
Renin 1644
Aldosterone 328
TSH 0.77
Free T4 26.939
U/O
900
820
BW
57.9
57.2
BUN
51
51.4
Crea
1.87
2.63
Na
127
123
K
4.5
4.2
Ca
8.2
7.7
P
2.7
3.0
C02
400
810
710
59.5
60.7
194/87
mmHg
172/79
mmHg
172/69
mmHg
151/70
mmHg
209/86
mmHg
U/O
400
1210
700
300
400
BW
61.6
61.1
61.3
62.4
BUN
58.7
63.3
72.8
Crea
2.59
2.31
3.12
Na
123
125
126
K
4.9
5.3
5.6
Ca
8.0
8.0
P
4.7
5.5
C02
15.4
17.3
179/82
mmHg
156/76
mmHg
174/84
mmHg
169/82
mmHg
176/75
mmHg
Renin 995
U/O
1320
2500
600
300
950
BW
61.6
60
62
62
63.1
BUN
80.4
Crea
2.65
Na
128
K
4.8
Ca
8.2
P
6.0
C02
21.1
188/84
mmHg
193/85
mmHg
192/78
mmHg
201/95
mmHg
210/85
mmHg
650
200
600
H/D
U/O
2180
BW
61.8
BUN
80.7
47
Crea
3.01
2.08
Na
123
130
K
3.9
3.8
Ca
7.9
8.7
P
5.1
2.7
C02
1400
203/90
mmHg
191/83
mmHg
204/90
mmHg
174/75
mmHg
172/95
mmHg
U/O
450
700
300
130
90
BW
58.2
BUN
58.1
Crea
3.12
Na
127
K
4.1
Ca
8.4
P
4.3
C02
22.5
177/81
mmHg
178/96
mmHg
196/89
mmHg
179/88
mmHg
202/89
mmHg
Hickman
implantation
U/O
BW
100
80
150
230
58.7
BUN
47.3
Crea
4.78
Na
127
K
4.9
Ca
7.9
P
3.6
C02
24.9
0
168/74
mmHg
164/87
mmHg
163/69
mmHg
141/74
mmHg
168/76
mmHg
500
600
Renal angiography
U/O
0
750
650
BW
54.9
BUN
37.5
Crea
4.83
Na
134
K
4.3
Ca
8.0
P
4.6
C02
23.7
197/85
mmHg
151/69
mmHg
168/79
mmHg
122/61
mmHg
161/74
mmHg
1100
2250
1300
950
Hold H/D
U/O
1100
BW
BUN
37.9
44.5
Crea
4.92
4.57
Na
131
131
K
4.4
4.5
Ca
7.8
8.5
P
4.9
5.4
C02
23.4
22.6
1/17 remove hickman
U/O
BW
147/81
mmHg
134/64
mmHg
1450
1400
119/54
mmHg
50.2
BUN
36.5
19.6
Crea
2.83
1.74
Na
133
136
K
4.4
5.0
Ca
9.0
8.6
P
4.2
4.0
C02
Renal Artery Stenosis: Optimizing Diagnosis and Treatment
Progress in Cardiovascular Diseases 54 (2011) 29–35
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1st: atherosclerotic lesions, 90% of all
renovascular lesions
◦ Typically in older individuals
◦ An equal prevalence in men and women
◦ Predominantly at or near the origin of the renal
artery and usually are associated with aortic disease
◦ May present with hypertension or renal insufficiency
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2nd: fibromuscular dysplasia (FMD)
◦ More often in young women
◦ Usually associated with hypertension without renal
insufficiency
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A limited literature addresses the clinical
factors that are predictive of finding
atherosclerotic RAS and that may be useful in
guiding appropriate screening.
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Doppler ultrasound
Computed tomography angiography (CTA)
and magnetic resonance angiography (MRA)
Conventional angiography
Imaging For Renovascular Disease
Seminars in Nephrology, Vol 31, No 3, May 2011, pp 272-282
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Duplex ultrasonography: screening test
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Sensitivity: 92.5% to 98%; specificity: 96% to 98%
Nontoxic
No exposure to ionizing radiation
Capable and reliable
Major limitation: dependence on technician skill for
acquisition of adequate images; others: obesity,
bowel gas, and recent food intake
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Computed tomography angiography (CTA):
◦ Sensitivity and specificity: > 95%
◦ Multicenter Renal Artery Diagnostic Imaging
Study in Hypertension (RADISH) study  SEN 64%,
SPE 93%
◦ Qualitative
◦ Risk of contrast nephropathy
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Magnetic resonance angiography (MRA):
◦ Slightly lower sensitivities and specificities than
CTA; RADISH study  SEN 62%, SPE 84%
◦ To measure flow, renal perfusion, and renal
function
◦ Poorer spatial resolution, limited availability, patient
tolerance, and the need for extended breathholding
◦ Nephrogenic sclerosing fibrosis associated with
Gadolinium in patients with renal insufficiency
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Duplex ultrasonography is inferior to MRA
and CTA.
Diagnostic tests for renal artery stenosis in patients
suspected of having renovascular hypertension: a
meta-analysis. Ann Intern Med 2001;135:401-411.
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Captopril renography:
◦ Poor screening test
 Dependent on comparative imaging of the right and
left kidneys
 The incidence of bilateral RAS is approximately 30%.
◦ May be useful when trying to determine the
physiologic significance of a known intermediate
stenosis
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Invasive angiography: gold standard
◦ Confirm the diagnosis based on prior noninvasive
testing and with the intent to perform an
intervention
◦ The most commonly used methodology: intraarterial digital subtraction angiography
◦ Complications: related to the vascular access,
placement of the guidecatheter into the renal
artery, balloon and stent deployment, and contrast
administration
◦ Carbon dioxide (CO2)
 Image quality is reduced.
 May create greater uncertainty about lesion severity
unless combined with judicious use of iodinated
contrast
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Medical therapy
Revascularization: balloon angioplasty +stenting or Surgical bypass or reconstruction
Goals:
◦ Blood pressure control
◦ Treatment of heart failure and/or pulmonary edema
◦ Prevention of nephropathy
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Medical therapy
Lifestyle interventions:
◦ Dietary recommendations in atherosclerotic RAS:
 Increased intake of fruits and vegetables, dietary
calcium through low fat dairy products
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Angiotensin-converting enzyme (ACE)
inhibitors
◦ Potential to induce acute hemodynamically
mediated renal failure in patients with RAS
◦ Lower cardiovascular event rates (10% vs 13%) and
need for dialysis (1.5% vs 2.5%)
◦ The cost of an increased risk of hospitalization for
acute renal failure (1.2 vs 0.6%)
 Selection bias: patients with better renal function
and/or less severe disease are treated with these
agents resulting in an apparent improvement of
outcome
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Other agents used to control the
atherosclerotic process are important for the
care of patients with atherosclerotic RAS.
◦ Statins: decrease death, limit lesion progression,
and promote restenosis-free survival
◦ Platelet inhibitors: prevention of future
cardiovascular events
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Revascularization:
◦ Balloon angioplasty +- stenting:
 Lesion severity, renal function, the skill level of the
operators, and complication rates
◦ Surgical bypass or reconstruction:
 Not benefit over angioplasty
 High rates of adverse outcomes with surgery, including
perioperative mortality of approximately 10%
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When stenting is performed, there are a
number of technical factors that should be
considered as part of the procedure.
◦ “No touch” technique for engaging a catheter into
the renal artery  reduce the risk of
atheroembolism
◦ No embolic protection device is approved by the
Food and Drug Administration for use in the renal
artery.
◦ Abciximab (a platelet glycoprotein IIbIIIa inhibitor)
??
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A “cure” of hypertension with
revascularization
◦ < 10% in patients with atherosclerotic RAS
◦ Approximately 50% in patients with FMD
 Younger patients more likely to achieve this outcome.
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Consistent and sustained blood pressure–
lowering effect of revascularization
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Considerable controversy exists regarding the
use of revascularization of atherosclerotic
RAS to treat or prevent the development of
ischemic nephropathy.
◦ Stent revascularization in patients with ischemic
nephropathy and significant stenoses resulted in a
slower rate of progression of nephropathy.
◦ In a minority of patients, an actual improvement in
renal function is seen with either stenting or
surgical revascularization.
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FMD: balloon angioplasty
◦ In a minority of FMD cases, there will be
concomitant aneurysms of the renal artery.
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Atherosclerotic RAS
◦ Stenting has proven superior to balloon
angioplasty.
Left kidney: 9.9 cm
Right kidney: 7.7 cm
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Right renal artery: occluded
Left renal artery: proximal 71% stenosis
◦ Balloon dilatation procedures: 56% residual stenosis
◦ Stenting: 5% residual stenosis