1. 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

2.  Name: 張 O 嗣  Sex: female  Age: 90-year-old  Chart number: 487733  Date of admission: 2011/11/18

3.  Persistent dizziness for 1 day

4.  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

5.  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

6.  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

7.  Allergy: no known allergy  Alcohol: denied; betel-nut: denied; cigarette: denied  Over-the-counter medication or chinese herb: nil

8.  No family history of malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases

9.  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

10. WBC6.2x1000/ul Hgb8.3 g/dl Hct25.4 % MCV87 fL PLT159 x1000/uL Segment78.9 % BUN118.1 mg/dL Creatinine4.43 mg/dl GPT9 IU/L Na134 mEq/L K8.2 mEq/L Ca8.2 mg/dL Mg2.3 mEq/L Tropo - I<0.01 ng/mL

11.  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

12. H/D U/O2020660740860 BW55.4654.855.956.6 BUN118.158.8 Crea4.432.65 Na134138 K8.55.1 Ca P C0221.3 189/88 mmHg 141/72 mmHg 149/70 mmHg 165/79 mmHg

13. U/O23016302450350920 BW69.559.158.3 BUN68.773 Crea2.822.45 Na125123 K4.75.0 Ca8.38.0 P4.84.5 C02 190/99 mmHg 159/72 mmHg 186/84 mmHg 206/94 mmHg 186/89 mmHg Kidney echo

14. U/O900820400810710 BW57.957.259.560.7 BUN5151.4 Crea1.872.63 Na127123 K4.54.2 Ca8.27.7 P2.73.0 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

15. U/O4001210700300400 BW61.661.161.362.4 BUN58.763.372.8 Crea2.592.313.12 Na123125126 K4.95.35.6 Ca8.0 P4.75.5 C0215.417.3 194/87 mmHg 172/79 mmHg 172/69 mmHg 151/70 mmHg 209/86 mmHg

16. U/O13202500600300950 BW61.66062 63.1 BUN80.4 Crea2.65 Na128 K4.8 Ca8.2 P6.0 C0221.1 179/82 mmHg 156/76 mmHg 174/84 mmHg 169/82 mmHg 176/75 mmHg Renin 995

17. U/O21801400650200600 BW61.8 BUN80.747 Crea3.012.08 Na123130 K3.93.8 Ca7.98.7 P5.12.7 C02 188/84 mmHg 193/85 mmHg 192/78 mmHg 201/95 mmHg 210/85 mmHg H/D

18. U/O45070030013090 BW58.2 BUN58.1 Crea3.12 Na127 K4.1 Ca8.4 P4.3 C0222.5 203/90 mmHg 191/83 mmHg 204/90 mmHg 174/75 mmHg 172/95 mmHg

19. U/O100801502300 BW58.7 BUN47.3 Crea4.78 Na127 K4.9 Ca7.9 P3.6 C0224.9 177/81 mmHg 178/96 mmHg 196/89 mmHg 179/88 mmHg 202/89 mmHg Hickman implantation

20. U/O0750650500600 BW54.9 BUN37.5 Crea4.83 Na134 K4.3 Ca8.0 P4.6 C0223.7 168/74 mmHg 164/87 mmHg 163/69 mmHg 141/74 mmHg 168/76 mmHg Renal angiography

21. U/O1100 22501300950 BW BUN37.944.5 Crea4.924.57 Na131 K4.44.5 Ca7.88.5 P4.95.4 C0223.422.6 197/85 mmHg 151/69 mmHg 168/79 mmHg 122/61 mmHg 161/74 mmHg Hold H/D

22. U/O14501400 BW50.2 BUN36.519.6 Crea2.831.74 Na133136 K4.45.0 Ca9.08.6 P4.24.0 C02 147/81 mmHg 134/64 mmHg 119/54 mmHg 1/17 remove hickman

23. Renal Artery Stenosis: Optimizing Diagnosis and Treatment Progress in Cardiovascular Diseases 54 (2011) 29–35

24.  1 st : 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

25.  2 nd : fibromuscular dysplasia (FMD) ◦ More often in young women ◦ Usually associated with hypertension without renal insufficiency

26.  A limited literature addresses the clinical factors that are predictive of finding atherosclerotic RAS and that may be useful in guiding appropriate screening.

28.  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

29.  Duplex ultrasonography: screening test ◦ 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

32.  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

33.  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 breath- holding ◦ Nephrogenic sclerosing fibrosis associated with Gadolinium in patients with renal insufficiency

34.  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.

35.  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

36.  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: intra- arterial digital subtraction angiography ◦ Complications: related to the vascular access, placement of the guidecatheter into the renal artery, balloon and stent deployment, and contrast administration

37. ◦ Carbon dioxide (CO2)  Image quality is reduced.  May create greater uncertainty about lesion severity unless combined with judicious use of iodinated contrast

38.  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

39.  Medical therapy  Lifestyle interventions: ◦ Dietary recommendations in atherosclerotic RAS:  Increased intake of fruits and vegetables, dietary calcium through low fat dairy products

40.  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

41.  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

42.  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%

43.  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) ??

44.  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.  Consistent and sustained blood pressure– lowering effect of revascularization

45.  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.

46.  FMD: balloon angioplasty ◦ In a minority of FMD cases, there will be concomitant aneurysms of the renal artery.  Atherosclerotic RAS ◦ Stenting has proven superior to balloon angioplasty.

49. Left kidney: 9.9 cm Right kidney: 7.7 cm

50.  Right renal artery: occluded  Left renal artery: proximal 71% stenosis ◦ Balloon dilatation procedures: 56% residual stenosis ◦ Stenting: 5% residual stenosis