Systematic Review: Comparative Effectiveness of Management Strategies for Renal Artery Stenosis

19 December 2006 | Volume 145 Issue 12

Background: Atherosclerotic renal artery stenosis is increasingly common in an aging population. Therapeutic options include medical treatment only or revascularization procedures.

Purpose: To compare the effects of medical treatment and revascularization on clinically important outcomes in adults with atherosclerotic renal artery stenosis.

Data Sources: The MEDLINE database (inception to 6 September 2005) and selected reference lists were searched for English-language articles.

Study Selection: The authors selected prospective studies of renal artery revascularization or medical treatment of patients with atherosclerotic renal artery stenosis that reported mortality rates, kidney function, blood pressure, cardiovascular events, or adverse events at 6 months or later after study entry.

Data Extraction: A standardized protocol with predefined criteria was used to extract details on study design, interventions, outcomes, study quality, and applicability. The overall body of evidence was then graded as robust, acceptable, or weak.

Data Synthesis: No study directly compared aggressive medical therapy with angioplasty and stent placement. Two randomized trials compared angioplasty without stent and medical treatments. Eight other comparative studies and 46 cohort studies met criteria for analysis. Studies generally had poor methodologic quality and limited applicability to current practice. Overall, there was no robust evidence. Weak evidence suggested no large differences in mortality rates or cardiovascular events between medical and revascularization treatments. Acceptable evidence suggested similar kidney-related outcomes but better blood pressure outcomes with angioplasty, particularly in patients with bilateral disease. Improvements in kidney function and cure of hypertension were reported among some patients only in cohort studies of angioplasty. Available evidence did not adequately assess adverse events or baseline characteristics that could predict which intervention would result in better outcomes.

Limitations: The evidence from direct comparisons of interventions is sparse and inadequate to draw robust conclusions.

Conclusions: Available evidence does not clearly support one treatment approach over another for atherosclerotic renal artery stenosis.

Editors' Notes Context Is medical therapy as effective as revascularization for atherosclerotic renal artery stenosis? Contribution This systematic review found no trials that compared aggressive medical therapy and angioplasty with stent in adults with atherosclerotic renal artery stenosis. Some evidence suggested similar kidney outcomes but better blood pressure outcomes with angioplasty, particularly in patients with bilateral renal disease. Weak evidence suggested no large differences in mortality or cardiovascular events between medical and revascularization treatments. No evidence directly compared adverse event rates between treatments. Implications Available evidence comparing benefits and harms of modern treatments for atherosclerotic renal artery stenosis is sparse and inconclusive. —The Editors

 

Author and Article Information

From Tufts-New England Medical Center, Boston, Massachusetts.

Note: The full report is available at www.effectivehealthcare.ahrq.gov/reports/final.cfm.

Disclaimer: The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Grant Support: This project was funded under contract no. 290-02-0023 from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Ethan Balk, MD, MPH, Tufts-New England Medical Center, Box 63, 750 Washington Street, Boston, MA 02111; e-mail, ebalk{at}tufts-nemc.org.

Current Author Addresses: Drs. Balk, Raman, Chung, Ip, Tatsioni, and Lau and Ms. Chew: Tufts-New England Medical Center, Box 63, 750 Washington Street, Boston, MA 02111.

Dr. Alonso: Tufts-New England Medical Center, Box 235, 750 Washington Street, Boston, MA 02111.

Dr. Gilbert: Tufts-New England Medical Center, Box 391, 750 Washington Street, Boston, MA 02111.