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Caielli, Paola (2015) Atherosclerotic Renovascular hypertension: Results of The METRAS study (Medical and Endovascular Treatment of Atherosclerotic Renal Artery Stenosis). [Tesi di dottorato]

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Abstract (inglese)

Background: Despite the results of some randomized controlled trials in the last 5 years it remains unclear whether revascularization of atherosclerotic renal artery stenosis (ARAS) by means of percutaneous renal angioplasty and stenting (PTRAS) is advantageous over optimal medical therapy. Materials and methods: The METRAS study was designed with the primary objective to determine whether PTRAS is superior or equivalent to optimal medical treatment for preserving glomerular filtration rate (GFR) in the ischemic kidney, as assessed by 99mTc-DTPA renal scintigraphy. Secondary objectives were to establish whether the two treatments are equivalent in lowering blood pressure, preserving overall renal function and regressing target organ damage. Results: At 2 years follow-up compared to the medical treatment in the endovascular group GFR in the ischemic kidney was higher (p=0.027). Moreover, 24 hours DBP was lower in PTRAS group compared to medical therapy at 3 years follow-up (p=0.029). Of note, this difference occurred despite borderline significant (p=0.055) lower need for number of antihypertensive drugs. Both serum creatinine and cystatin-c were lower in PTRAS group compared to medical therapy (p=0.035 and p=0.02, respectively). HBA1c was also lower in PTRAS group compared to medical therapy (p=0.034). Left ventricular mass index, as assessed by echocardiography, was also borderline significant (p=0.058) lower in the PTRAS group. Diastolic dysfunction, as assessed by E/E’ ratio at tissue Doppler, improved in the PTRAS group compared to medical therapy (p=0.011). Conclusions: In the carefully selected patients with atherosclerotic renovascular hypertension of the METRAS study PTRAS on top of optimal medical therapy provided an improvement in GFR in the ischemic kidney and a better DBP control despite a lower need of antihypertensive drugs compared to optimally treated patients receiving medical therapy only.

Abstract (italiano)

Background: la stenosi delle arterie renali è una delle cause principali d'insufficienza renale e d’ipertensione arteriosa secondaria. Studi epidemiologici hanno dimostrato che la stenosi dell’arteria renale su base aterosclerotica implica non solo un elevato profilo di rischio cardiovascolare, ma anche un'aumentata incidenza di morbilità e mortalità per stroke, cardiopatia ischemica e arteriopatia periferica. La rivascolarizzazione percutanea con angioplastica transluminale e stenting è divenuta il trattamento di scelta, per lo meno nei pazienti in cui la terapia medica non consente un soddisfacente controllo dei valori pressori e per i quali è presumibile che la rivascolarizzazione possa ritardare o prevenire il declino della funzione renale. La reale utilità di tale costosa procedura rimane, tuttavia, fortemente dibattuta, poiché gli studi clinici prospettici randomizzati di confronto fra trattamento endovascolare e sola terapia medica pubblicati fino ad ora non sono stati conclusivi nel dimostrare una superiorità di un trattamento sull’altro. Materiali e metodi: lo studio METRAS è stato disegnato con l’obiettivo primario di determinare se la rivascolarizzazione sia superiore o equivalente alla sola terapia medica nel preservare la funzione renale nel rene ischemico valutata con la scintigrafia renale al 99mTc-DTPA nei pazienti con stenosi aterosclerotica delle arterie renali. Obiettivi secondari includono il controllo pressorio, la preservazione della funzione renale globale e la regressione del danno d’organo. Risultati: nel gruppo trattato con terapia endovascolare la GFR nel rene ischemico misurata alla scintigrafia è risultata più alta rispetto al gruppo in terapia medica a 2 anni di follow-up (p=0.027). La pressione diastolica nelle 24 ore è risultata inferiore nel gruppo in trattamento endovascolare rispetto al braccio in terapia medica a 3 anni di follow-up (p=0.029) a fronte di un minore utilizzo di farmaci antipertensivi nel braccio endovascolare (p=0.055). I livelli di creatinina, cistatina-c ed emoglobina glicata sono risultati inferiori nei pazienti nel braccio endovascolare rispetto ai pazienti in sola terapia medica (rispettivamente p=0.035, p=0.020, e p=0.034). La massa ventricolare sinistra normalizzata per altezza è risultata inferiore nei pazienti trattati con trattamento endovascolare rispetto ai pazienti in terapia medica, seppur la significatività sia borderline (p=0.058) a fronte di un miglioramento della disfunzione diastolica, espressa come rapporto E/E’, in questo gruppo di pazienti rispetto al braccio in terapia medica (p=0.011). Conclusioni: lo studio METRAS ha dimostrato un miglioramento della GFR nel rene ischemico, un migliore controllo pressorio in termini di pressione diastolica nelle 24 ore ed un minor fabbisogno di farmaci antipertensivi nei pazienti trattati con angioplastica e stenting rispetto al gruppo in sola terapia medica.

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Tipo di EPrint:Tesi di dottorato
Relatore:Rossi, Gian Paolo
Dottorato (corsi e scuole):Ciclo 27 > corsi 27 > Ipertensione Arteriosa e Biologia Vascolare
Data di deposito della tesi:28 Aprile 2015
Anno di Pubblicazione:2015
Parole chiave (italiano / inglese):renal artery stenosis; revascularization; angioplasty; glomerular filtration rate
Settori scientifico-disciplinari MIUR:Area 06 - Scienze mediche > MED/11 Malattie dell'apparato cardiovascolare
Struttura di riferimento:Dipartimenti > Dipartimento di Medicina
Codice ID:8762
Depositato il:16 Nov 2015 15:04
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