腎血管病的處理課件

1、Management of Renovascular Hypertension阜外心血管病醫(yī)院心內(nèi)科蔣雄京腎血管病的處理1Management of Renovascular Hy Interrelation among Renal Artery Stenosis, Hypertension, and Chronic Renal Failure 腎血管病的處理2 Interrelation among Renal Art Definition of Renal Artery StenosisRenal artery stenosis (RAS) is defined as narrowing

2、of the lumen of the renal artery. *angiographic diameter stenosis50%*translesional pressure gradient of 20 mm Hg peak systolic or 10 mm Hg mean The most common causes of RAS are atherosclerosis (80%) , aortoarteritis(15%), and fibromuscular dysplasia(50% 9.7Bilateral, %1.7IndicationSuspected CHDWang

3、 et al23014.8NRCHDShen et al28015.35.0Suspected CHDLiu et al14118.4NRSuspected CHDMean185111.8NR腎血管病的處理7Incidence of Renal Artery Sten腎血管病的處理8腎血管病的處理8Progressive Atherosclerosis, Renal Artery Stenosis, and Ischemic Nephropathy 腎血管病的處理9Progressive Atherosclerosis, Rthe clinical manifestations of ARVD

4、 腎血管病的處理10the clinical manifestations ofClinical features suggestive of renovascular hypertensionJNC-VI Onset of hypertension aged30 y;Abdominal bruit;Accelerated or resistant hypertension;Flash pulmonary edema with normal left ventricular function;Renal failure of uncertain cause;Coexisting, diffus

5、e atherosclerotic vascular diseaseAcute renal failure precipitate by antihypertensive therapy, particularly ACEI or AII receptor blockers; In the presence of these clinical clues the prevalence of RVH is 40%.腎血管病的處理11Clinical features suggestive oScreening for Renovascular Hypertension1 .Radionuclid

6、e renal fractional flow /GFR2. Plasma renin activity3. Captopril renoscitigraphy4. Color dopplor ultrasonography5. MR Angiography / CT Angiography腎血管病的處理12Screening for Renovascular HypMulti-slices CTA is most useful for RAS screening腎血管病的處理13Multi-slices CTA is most usefuSeverity of renal vascular

7、disease predicts mortality in patients undergoing coronary angiographyKidney International (2001) 60, 14901497腎血管病的處理14Severity of renal vascular dis腎血管病的處理15腎血管病的處理15Clinical Criteria for RevascularizationHypertension: accelerated hypertension; refractory hypertension; malignant hypertension; hyper

8、tension with a unilateral small kidney; or hypertension with intolerance to medication. Renal salvage: sudden unexplained worsening of renal function; impairment of renal function secondary to antihypertensive treatment, particularly with an angiotensin-converting enzyme inhibitor or angiotensin II

9、receptor blocker; or renal dysfunction not attributable to another cause. Cardiac disturbance syndromes: recurrent flash pulmonary edema out of proportion to any impairment of left ventricular function,or unstable angina in the setting of significant RAS.腎血管病的處理16Clinical Criteria for RevasculMedica

10、l Therapy control of blood pressure : ACE inhibitors or Angiotensin receptor blockers ?antiplatelet therapysmoking cessationaggressive control of hyperlipidemia and DM The best medical therapy for ARVD remains unclear. Medical therapy hardly prevents renal function worsen in patients with bilateral

11、RAS or RAS of single kidney. Chabova V, et al. Mayo Clin Proc 2000;75:437-444 Baboolal K Am J Kidney Dis 1998;31:971-977腎血管病的處理17Medical Therapy control of blo腎動(dòng)脈支架置入 腎血管病的處理18腎動(dòng)脈支架置入 腎血管病的處理18meta-analysis data demonstrating superiority of renal artery stent compared with balloon angioplasty for pr

12、ocedure success and restenosis rates腎血管病的處理19meta-analysis data demonstrati術(shù)前準(zhǔn)備阿斯匹林0.10.3 QD, 氯吡格雷75mg QD ，2-3天;降壓,血壓控制在90%）腎血管病的處理27Case report -1女，60歲，發(fā)現(xiàn)高血壓2年，最高腎血管病的處理28腎血管病的處理28 GFR 左（min/l） 右（ min/l ）術(shù)前 24.0 20.4術(shù)后（第3天) 21.3 34.6腎照相（99mTc-DTPA）腎血管病的處理29 GFR 左（mi術(shù)后隨訪拜新同30mg,Qd;阿托伐他丁10mg,Qn;阿斯匹林0

13、.1 ,Qd;氯吡格雷75mg,Qd,1個(gè)月術(shù)后2周 ：Bp120/82mmHg,Cr125.4umol/L,BUN7.39mmol/L術(shù)后6個(gè)月 ：Bp132/86mmHg,Cr115umol/L,BUN6.2 mmol/L術(shù)后12個(gè)月：Bp128/84mmHg,Cr118umol/L,BUN7.2 mmol/L術(shù)后18個(gè)月：Bp136/88mmHg,Cr128umol/L,BUN7.9 mmol/L腎血管病的處理30術(shù)后隨訪拜新同30mg,Qd;阿托伐他丁10mg,Qn;阿斯ARVD Randomized StudiesPTRA vs Medication腎血管病的處理31ARVD Ran

14、domized Studies腎血管病的腎動(dòng)脈支架的臨床結(jié)果文獻(xiàn)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FMD 50 85% 85 - 100%ARAS 5 15% 50 70%TA 40 - 60% 75 - 90%腎血管病的處理32腎動(dòng)脈支架的臨床結(jié)果文獻(xiàn)匯總分析： ASTRALAngioplasty and STent for Renal Artery LesionsUK MULTI-CENTRE TRIAL INATHEROSCLEROTIC RENOVASCULAR DISEASEPhilip A KalraLead Nephrologist f

15、or ASTRAL, Hope Hospital, Salford, UK,On behalf of the ASTRAL TMC and collaborators腎血管病的處理33ASTRALPhilip A Kalra腎血管病的處理33ASTRAL Trial: Design806403 Medical Rx 403 Stent Assigned308 Stent(76%)44 NotAttempted17 Failed34 NotKnown腎血管病的處理34ASTRAL Trial: Design806403 MedPrimary and secondary end points in

16、 ASTRALPrimary end point Secondary end points Blood pressure controlRenal events (such as acute renal failure, dialysis, transplant or nephrectomy)Serious vascular events (such as myocardial infarction, angina or stroke)MortalityRate of progression of renal dysfunction (using serum creatinine analys

17、ed by reciprocal creatinine plots over time)腎血管病的處理35Primary and secondary end poin Stent Med Rx p ValueAge 70 71 NSMale 63% 63% NSDiabetes 31% 29% NSCr 179 178 NSGFR 40 39 NSBilateral 50% 50% NSACE/ARB 47% 38% NSBaseline Characteristics腎血管病的處理36 Stent Med Rx ASTRAL: Lesion SeverityMean = 76% (Range

18、: 20% 100%)Site reported: no core labNo. of patientsStenosis(%)腎血管病的處理37ASTRAL: Lesion SeverityMean = ASTRAL: TreatmentRevascularization Strategies:Stenting 93% PTA alone 7%Post-stent residual stenosis 50%: 12%Complications: 7% Perforations: 4 (1%) Cholesterol Emboli 3 (1%) Death 180/110 mmHg或正規(guī)三聯(lián)降壓

19、藥治療血壓140/90mmHg；(3)血肌酐7.0cm，并且殘余的GFR10ml/min；(5)年齡30歲，性別不限。排除標(biāo)準(zhǔn)：(1)病情不穩(wěn)定，無(wú)法耐受介入治療；(2)造影劑過(guò)敏；(3)腎動(dòng)脈病變的解剖條件不適合進(jìn)行介入治療 腎血管病的處理51資料與方法本研究病例入選標(biāo)準(zhǔn)：腎血管病的處理51結(jié)果-患者的基本臨床特征 患者(n=238)的基線臨床特征年齡(歲)3383(64.29.5)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、)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(NYHA級(jí)),例(%)17(7.1)腎血管病的處理52結(jié)果-患者的基本臨床特征 患者(n=238)的基線臨床特征年結(jié)果-患者的基本臨床特征患者(n=238)的基線臨床特征(續(xù)) 高血壓病史(月)1600(159.5143.9)收縮壓(mmHg)161.622.2舒張壓(mmHg)94.68.8服用降壓藥種類數(shù)(種)15(2.91.6)狹窄程度(%)60100(82.98.1)單側(cè)腎動(dòng)脈狹窄,例(%)172(72

21、.3)雙側(cè)腎動(dòng)脈狹窄,例(%)66(27.7)開(kāi)口和(或)近端狹窄,條(%)292(95.4)中遠(yuǎn)端狹窄,條(%)14(4.6)術(shù)前管腔直徑(mm)02.45(1.00.5)血肌酐水平(umol/L)44.0263.92(108.942.3) 血肌酐133umol/L,例(%)202(84.9) 血肌酐133177umol/L,例(%)26(10.9) 血肌酐177umol/L,例(%)10(4.2)血尿素水平(mmol/L)2.923.8(7.53.3)腎血管病的處理53結(jié)果-患者的基本臨床特征患者(n=238)的基線臨床特征(續(xù)PTRAS的造影和支架結(jié)果及并發(fā)癥 238例患者中2例的2條腎

22、動(dòng)脈發(fā)生嚴(yán)重夾層，1例的1條分支血管被支架壓閉，總的血運(yùn)重建技術(shù)成功率99%(303/306)。PTRAS相關(guān)并發(fā)癥總計(jì)5.5%(13/238).并發(fā)癥轉(zhuǎn)歸股動(dòng)脈穿刺點(diǎn)大血腫2例，出血1例均經(jīng)輸血和延長(zhǎng)加壓包扎后治愈股動(dòng)脈穿刺點(diǎn)假性動(dòng)脈瘤形成1例經(jīng)外科手術(shù)修補(bǔ)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(jìn)行性下降2例考慮系腎動(dòng)脈穿孔所致，經(jīng)輸血后好轉(zhuǎn)，隨訪觀測(cè)基本吸收腦卒中3例缺血性2例，1例無(wú)后遺癥，1例有后遺癥，出血性1例，術(shù)后第3日死亡腎血管病的處理54PTRAS的

23、造影和支架結(jié)果及并發(fā)癥 238例患者中2例的2條結(jié)果-隨訪及失訪情況 隨訪時(shí)間(月)61218243036424854606672應(yīng)有人數(shù)(例)238225193159134112967563453726實(shí)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(shí)際隨訪到的存活人數(shù)(例)22120818114611998826048302211 隨訪672(29.219.6)個(gè)月，共失訪23例(9.7%)腎血管病的處理55結(jié)果-隨訪及失訪情況 隨訪時(shí)間(月)612182430364PTRAS

24、對(duì)血壓的影響臨床判定的支架內(nèi)再狹窄率3.0%(7/238)腎血管病的處理56PTRAS對(duì)血壓的影響臨床判定的支架內(nèi)再狹窄率3.0%(7/PTRAS對(duì)腎功能的影響腎血管病的處理57PTRAS對(duì)腎功能的影響腎血管病的處理57PTRAS后血壓和腎功能轉(zhuǎn)歸36例術(shù)前腎功能異常的患者，PTRS后腎功能改善21例(77.8%)無(wú)變化9例(25%) ，惡化3例(8.3%)(其中2例發(fā)展至腎衰竭尿毒癥期，已行透析治療)，失訪2例(5.6%) ，死亡1例(2.7%)。 術(shù)后6、12個(gè)月時(shí)患者的血壓和腎功能轉(zhuǎn)歸(例)觀察時(shí)間例數(shù)血壓肌酐治愈改善無(wú)效改善無(wú)變化惡化術(shù)后6個(gè)月221(100)3(1.4)184(83.

25、2)34(15.4)71(32.1)133(60.2)17(7.7)術(shù)后12個(gè)月208(100)5(2.4)176(84.6)27(13.0)65(31.3)122(58.7)21(10.0)腎血管病的處理58PTRAS后血壓和腎功能轉(zhuǎn)歸36例術(shù)前腎功能異常的患者，PT本研究PTRAS后的無(wú)事件生存率Severity of renal vascular disease predicts mortality in patients undergoing CAGKidney International (2001) 60, 14901497腎血管病的處理59本研究PTRAS后的無(wú)事件生存率Seve

26、rity of rePTRAS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%)腎血管病的處理60PTRAS后的心血管事件共發(fā)生心血管事件24例(10.1%)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(shì)比(95%CI)P心腦血管死亡術(shù)后12個(gè)月高血壓治愈或改善0.070(0.011-0.453)0.008術(shù)后12個(gè)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(gè)月高血壓治愈或改善0.002(0.000-0.15

27、1)0.005術(shù)后12個(gè)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(gè)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(gè)月高血壓治愈或改善0.098(0.019-0.499)0.005術(shù)后12個(gè)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)0.019腎血管病的處理61隨訪期患者發(fā)生各

28、種心血管事件的相關(guān)因素事件相關(guān)因素優(yōu)勢(shì)比Case 1: Bilateral renal artery stenoses in a aged 69 elderly with renal insufficiency, 3 antihypertensive medications, BP 178/88mmHg, Cr 187 umol/l Follow-upOne antihypertensive drug 3 days BP134/82mmHg,Cr132umol/l 14 days BP132/84mmHg,Cr118umol/l6 mons BP128/72mmHg,cr107umol/l12

29、mons BP126/76mmHg,cr112umol/l腎血管病的處理62Case 1: Bilateral renal arte Male, 61yr，Hypertension10yr，BP180/110mmHg with five antihypertensive medications. CHD, 2 years ago LAD PCI, Smoking, Hyperlipidimia SCr 205umol/l3 days after procedure BP132/84mmHg with two antihypertensive medications SCr128umol/l24

30、 months after procedure BP124/72 84mmHg with two antihypertensive medications SCr116umol/l腎血管病的處理63 Male, 61yr，Hypertension10yr，64-slices CTA finding on a female, 65 yo. High blood pressure 20 years ,Maximal BP 210/120mmHG, out of control with nifedipine IGTS 30mg qd, bisoprolol 5mg qd, and perindop

31、ril 4mg qd, for 5 years, Exacerbate 3m腎血管病的處理6464-slices CTA finding on a fe腎血管病的處理65腎血管病的處理65結(jié)論我們的單中心研究表明支架置入重建血運(yùn)治療粥樣硬化性腎動(dòng)脈嚴(yán)重狹窄有較好的安全性，中遠(yuǎn)期降壓和穩(wěn)定腎功能的獲益肯定。本研究也提示腎動(dòng)脈支架術(shù)有可能顯著減少心血管事件的發(fā)生率并降低死亡率，但還需要進(jìn)一步研究予以證實(shí)。 腎血管病的處理66結(jié)論我們的單中心研究表明支架置入重建血運(yùn)治療粥樣硬化性腎動(dòng)脈阜外醫(yī)院腎動(dòng)脈狹窄研究的現(xiàn)狀1999-至今已積累550例腎動(dòng)脈介入病例。近年來(lái)新來(lái)我院診治的腎動(dòng)脈狹窄患者300例/

32、年以上，實(shí)施介入治療病例150例/年，歐美國(guó)家達(dá)到如此規(guī)模的醫(yī)學(xué)中心不到5家。 腎血管病的處理67阜外醫(yī)院腎動(dòng)脈狹窄研究的現(xiàn)狀1999-至今已積累550例腎動(dòng)腎動(dòng)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(guó)際文獻(xiàn)95100%5076%415%0.31%腎血管病的處理68腎動(dòng)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)期死亡率阜外以腎功能不全的進(jìn)展率為主要終點(diǎn)事件的研究，如果要取得陽(yáng)性結(jié)果，則需要滿足二個(gè)關(guān)鍵點(diǎn)：1.病例入選要嚴(yán)格，即雙側(cè)或單功能腎的腎動(dòng)脈嚴(yán)重狹窄（70%）所致的缺血性腎病。對(duì)于單側(cè)腎動(dòng)脈狹窄,患腎較對(duì)照側(cè)腎功能下降至少25% 。

33、2. 從事腎動(dòng)脈介入的治療團(tuán)隊(duì)富有經(jīng)驗(yàn)，能有效防范介入對(duì)腎臟直接損害。 腎血管病的處理69以腎功能不全的進(jìn)展率為主要終點(diǎn)事件的研究，如果要取得陽(yáng)性結(jié)以控制高血壓為目的的腎動(dòng)脈支架術(shù)如果入選標(biāo)準(zhǔn)定在腎動(dòng)脈直徑狹窄50%，可能包括部分沒(méi)有血流動(dòng)力學(xué)意義的狹窄(50-70%)，腎動(dòng)脈支架術(shù)不但無(wú)效，而且要承擔(dān)介入治療本身的風(fēng)險(xiǎn)。實(shí)踐表明，入選患者要滿足二個(gè)關(guān)鍵點(diǎn)：1. 腎動(dòng)脈狹窄70%，且能證明狹窄與高血壓存在因果關(guān)系；2. 頑固性高血壓或不用降壓藥高血壓達(dá)III級(jí)水平。 腎血管病的處理70以控制高血壓為目的的腎動(dòng)脈支架術(shù)如果入選標(biāo)準(zhǔn)定在腎動(dòng)脈直徑狹如何保證腎動(dòng)脈支架術(shù)療效?1.嚴(yán)格把握腎動(dòng)脈介入的

34、適應(yīng)征2.防范介入對(duì)腎臟的直接損害，提高手術(shù)成功率。 腎血管病的處理71如何保證腎動(dòng)脈支架術(shù)療效?1.嚴(yán)格把握腎動(dòng)脈介入的適應(yīng)征腎動(dòng)脈支架術(shù)后急性腎功能損害的主要原因1. 介入操作過(guò)程中發(fā)生的腎動(dòng)脈栓塞 及其它損傷；2. 造影劑誘發(fā)的腎毒性；3. 血容量不足導(dǎo)致的腎灌注不足。 腎血管病的處理72腎動(dòng)脈支架術(shù)后急性腎功能損害的主要原因1. 介入操作過(guò)程中發(fā)重視控制危險(xiǎn)因素ARVD是全身動(dòng)脈粥樣硬化的一部分，腎動(dòng)脈支架術(shù)成功并不意味著動(dòng)脈粥樣硬化進(jìn)程的終止。降脂治療、降糖治療、降壓治療及阿斯匹林等對(duì)防止動(dòng)脈粥樣硬化發(fā)展有深遠(yuǎn)的影響，對(duì)預(yù)防心血管并發(fā)癥有重大意義，應(yīng)予高度重視。 腎血管病的處理73重

35、視控制危險(xiǎn)因素ARVD是全身動(dòng)脈粥樣硬化的一部分，腎動(dòng)脈支纖維肌性結(jié)構(gòu)不良(FMD)及大動(dòng)脈炎所致的腎動(dòng)脈狹窄 PTA的指征相對(duì)寬松 ： 1.腎動(dòng)脈狹窄50%; 2.持續(xù)高血壓160/100mmHg大動(dòng)脈炎活動(dòng)期不宜手術(shù)，一般要用糖皮質(zhì)激素治療使血沉降至正常范圍后2個(gè)月以上方可考慮行PTA 一般不使用血管內(nèi)支架, 僅作為PTA失敗的補(bǔ)救措施 : 1.單純PTA治療FMD及大動(dòng)脈炎的結(jié)果很好; 2.這類病變放置支架遠(yuǎn)期結(jié)果并清楚。 腎血管病的處理74纖維肌性結(jié)構(gòu)不良(FMD)及大動(dòng)脈炎所致的腎動(dòng)脈狹窄 PTA Clinical outcomes of PTRA as Treatment for

36、Renal Artery Stenosis caused by aortoarteritis or FMDJiang Xiongjing, et al. Hypertension Division, Cardiovascular Institute and Fu Wai Hospital, CAMS and PUMC腎血管病的處理75 Clinical outcomes of PTRA asMETHODPatients selection for PTRAIn presence of renal artery 60% diameter stenosis,Patients had Poorly

37、controlled hypertension while receiving 3 antihypertensive medications or HBP grade III without antihypertensive medications. a. Increased renal vein renin b. Captopril Renoscitigraphy Positive c. serum creatinine level30% residual stenosis after PTA e. Longitudinal kidney length 7.0cm with GFR10ml/

38、minIndications for inclusion were not mutually exclusive.腎血管病的處理76METHODPatients selection for Clinical characteristics of 80 study patientsGENDER(m/f) 28/52AGE(YR) 1358 (29 14) ETIOLOGY(N) FIBROMUSCULAR DYSPLASIA 18(22.5%) ARTERITIS 62 (77.5%)Lesions stenoses(%) 60%100% (82 15) 腎血管病的處理77Clinical ch

39、aracteristics of 80Blood pressure response (SBP/DBP, mmHg) after PTRA baseline discharge 6month Arteritis 174.532.8/ 106.820.4 129.221.6/80.211.5* 134.625.3/83.413.6 *#FMD 156.426.8/ 104.612.4 126.415.2/75.69.8* 128.817.6/76.210.4 * No.of med 2.91.3 1.01.1 * 1.21.4*# *P0.001compared with baseline. #

40、 P0.05 compared with values at discharge. SBP= systolic blood pressure; DBP=diastolic blood pressure 腎血管病的處理78Blood pressure response (SBP/DThe effect of PTRA on hypertension at 6-month follow-up Etiology Cure(%) Improved(%) No improvement(%) Total (%) Arteritis 35(56.5) 19 (30.6) 8(12.9) 62 (100) FMD 14 (77.8) 3 (16.7) 1 (5.6) 18 (100) Cure:SBP140mmHg & DBP10% or DBP15% with taking same medications, SBP10% or DBP15% with taking fewer medications; No improvement: the aforementioned criteria were not met.Estimated restenosis rate: 8 pts with arteritis & 1 pts with FMD腎血管病的處理79The ef