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Acute renal failure in ischemic nephropathy
Jose L. Rodicio
Jose M. Alcazar
Servicio de Nefrología
Hospital 12 de Octubre
Universidad Complutense. Madrid
Out of the 72 patients diagnosed of ischemic nephropathy, a
group of 21 (29.1%) whose debut in renal insufficiency was acute renal failure (ARF) is
described. Of these, 12 cases could be attributed to the angiotensin-converting enzyme
inhibitor (ACEI) used to treat their hypertension and six to arterial thrombosis, either
from aortic thrombosis or from the renal arteries. In the three remaining cases, the ARF
was a consequence of coronariographies and there was one case of immunoallergic
In 71.4% of the cases, there were data suggesting the diagnosis of extrarenal vascular disease, although a renal angiography was needed to verify the diagnosis in every case.
Revascularization techniques (surgery in 13 cases and angioplasty/endoprothesis in 4) significantly improved the renal function in 19 patients, including five of them who required dialysis.
This is a disease whose prevalence is growing, that can be manifested as acute renal failure and whose evolution is very favorable with revascularization techniques.
Ischemic renal disease (IRD) is defined as a significant
reduction in the glomerular filtration rate in patients with hemodynamically significant
renovascular occlusive disease affecting the total functioning renal parenchyma.
Maintained renal ischemia produces nephronal mass and functional loss which is generally progressive. In these circumstances, the development of collateral circulation from suprarenal, capsular, pelvis or ureteral vesselly maintains the renal parenchyma alive, albeit without filtering function, because of diminished filtering pressure ("nonfunctioning kidney")(1). For this type of injury, some authors (2,3) have introduced the term "Ischemic Nephropathy," which implies a critical bilateral involvement. This terminology usually includes the renal insufficiency of vasculorenal hypertension and the chronic renal insufficiency accompanying atherosclerotic vascular disease (4). It has been difficult to determine the exact prevalence of IRD for several reasons. Eleven to 15 percent of end-stage renal disease cases are attributable to chronic IRD (5,6).
The prevalence of unsuspected renal artery stenosis (>50%) among patients with extrarenal vascular disease undergoing an angiography ranges from 11% to 42% (7).
There are six major clinical settings in which the clinician could suspect IRD (8):
1. acute renal failure caused by the treatment of
hypertension, especially with ACEI
2. progressive azotemia in a patient with known renovascular hypertension
3. acute pulmonary edema superimposed upon poorly controlled hypertension and renal failure
4. progressive azotemia in an elderly patient with refractory or severe hypertension
5. progressive azotemia in an elderly patient with evidence of atherosclerotic disease
6. unexplained progressive azotemia in an elderly patient.
The purpose of this study is to determine the prevalence of acute renal failure as a presentation form of ischemic nephropathy.
Patients and Methods
A total of 72 patients (table 1)
diagnosed of Ischemic Nephropathy (creatinine >1.5 mg/dl) by renography and duplex
sonography and verified by angiography were evaluated with the clinical history and
complementary examinations on the clinical manifestations which motivated the admission to
the hospital and/or study of the patient.
Table 2 shows the different clinical presentation forms of ischemic nephropathy. In 21 (29.1%) of these, an acute deterioration of the renal function (ARF), defined by sudden increase in serum creatinine (creatinine >2.0 mg/dl) and/or oligoanuria, stands out. The different causes responsible for the acute renal failure were investigated in each one of the patients.
The etiological causes of ARF (table no. 3) were a) administration of ACEI in 12 patients (57%); b) six cases of thrombosis of renal arteries caused by aortic thrombosis (Leriche Syndrome in 3) or isolated thrombosis of the renal artery/arteries in 3 patients; c) one case of atheroembolism, secondary to a coronariography and verified by renal biopsy (Fig. 1 and 2); d) one case of immunoallergic nephritis that could be attributed to furosemide, with histological demonstration; e) one case of toxicity due to radiocontrast agents, secondary to the performance of a coronariography.
Figure 3 corresponds to the aortographic study of a 51 year old male with a background of type II mellitus diabetes, arterial hypertension, angina type ischemic cardiopathy and claudication of lower limbs. He was being treated with Captopril and was admitted to the Emergency service of the Hospital with oliguria, acute lung edema and creatinine = 2.6 mg/dl. When the ACEI was discontinued and the cardiac failure controlled, the patient recovered diuresis and the serum creatinine decreased.
The aortogram revealed a Leriche Syndrome with thrombosis of the infrarenal aorta, thrombosis of the left renal artery and 80% stenosis of the right renal artery. After the viability of the right kidney was demonstrated by a renal scintigraphy, revascularizing surgery was performed with a aorta-bifemoral and right renal aorto bypass.
Figure 4 corresponds to an aortogram of a 52 year old male with a background of arterial hypertension and symptoms of lower limb claudication. He was admitted to the Emergency Service of the Hospital with complete anuria and creatinine of 10.0 mg/dl. Dialysis sessions were performed until the study was completed. The study showed thrombosis of the infrarenal aorta, thrombosis of both renal arteries with absence of nephrogram: on the left side, a distal part of the left renal artery was observed. The renal scintigraphy (fig. 5) showed positive uptake by the left kidney.
Based on these data, which verified the viability of the
left kidney and which Libertino (1,9) defined as "nonfunctioning kidney,"
surgery was performed with a bifemoral aorto and left aorto-renal bypass. Ten years later,
the patient maintains a creatinine level of 3.0 mg/dl and a clearance of 29 ml/ml.
In fifteen of the 21 patients with ARF, there are data of extrarenal atherosclerotic disease (table 4), and in 14 (66.6%) of them, symptoms of lower limb ischemia and one case with ischemic cardiopathy stand out.
Seven patients required temporary dialysis (3 days to 2 months) during the study phase.
In 12 patients with ARF due to an ACEI, discontinuing the treatment was sufficient for partial or total recovery of the renal function. In table 5, the treatment administered in relationship to the ARF responsible etiological cause is described. In a total of 13 patients, revascularizing surgery of the renal arteries, alone or associated to an aorto-bifemoral bypass was performed. In four cases, angioplasty, with placement of endoprothesis in two of the patients, was performed. In 19 patients (90.4%), there was significant improvement of the renal function, it standing out that six of the seven patients who required hemodialysis recovered their renal function.
The exact prevalence of end-stage renal failure secondary to ischemic nephropathy is unknown, but several authors estimate it to be between 11% to 15% of all the causes of renal failure (5,6).
The incidence of disease in the renal arteries in patients with extrarenal atheriosclerosis ranges from 11% to 42% (7) although the progression rate of the lesions and whether it is produced in all the patients are not known. Several prospective studies (10-13) have demonstrated that the vascular injury progresses in 36% to 70% of the cases, with complete thrombosis in the vessel lumen in 11% to 16% of all the patients.
It is unquestionable that we are facing a growing disease and that this should be considered in elderly patients, basically males, with a background of smoking, type II diabetes and signs of extrarenal atheriosclerosis. Thus, its presentation as acute renal failure is quite common, whether provoked by intraglomerular hemodynamic disorders secondary to the ACEI (14) or by acute thrombosis of the renal arteries (15).
In this series, a total of 21 patients diagnosed of ARF is presented; 18 of them with initial clinical manifestations of ischemic nephropathy and in the remaining three, the renal failure was produced due to complementary examinations or drugs used in their treatment. Thus, it is fundamental to consider this diagnostic possibility, especially if it appears in a patient with the previously described vascular profile. This is a complete disease, with high morbidity and mortality, but one in which the kidney is an organ that reacts well to the renal revascularization techniques since, in spite of the complete thrombosis of the renal artery, the kidney is maintained alive, although not functioning (1,9) thanks to an intense collateral circulation that becomes established over time.
Surgery is generally highly effective in preserving renal function in patients with bilateral renovascular disease. The success rate with surgical revascularization may be as high as 85 to 90 percent, approximately 55 to 65 percent of patients show improvement as evidenced by a fall in the plasma creatinine concentration, while another 30 percent have stable function (16-20).
With percutaneous angioplasty (PTRA), published reports suggest as much as 65 to 70 percent initial success rate, 35 to 50 percent improvement and 12 to 15 percent stable. There is an elevated incidence of restenosis (5% to 38%) (20-24) and in almost all the series there is a high percentage of patients with deterioration of the renal function in the short term. A method aimed at improving the results of PTRA in ostial lesions which decreases the incidence of restenosis consists in placing a balloon-expandable intravascular stent during the angioplasty (25-27).
In this series, a total of 19 patients (90.4%) recovered their renal function thanks to the renal revascularization techniques. This is a complete, but very well treated, disease if there is perfect organization and experience among the surgeons, radiologists and nephrologists.
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