Clinical Question

Does the use of renal artery stenting combined with aggressive medical therapy improve outcomes in patients with severe atherosclerotic renal artery stenosis?

Bottom Line

In patients with severe atherosclerotic renal artery stenosis and hypertension or chronic kidney disease, renal artery stenting does not provide an additional benefit when added to comprehensive medical therapy that includes blood pressure and diabetes mellitus management, and antiplatelet and lipid therapies. (Level of Evidence = 1b)

Synopsis

These investigators enrolled 947 patients with severe atherosclerotic renal artery stenosis (60% stenosis or more). Eligible patients also had systolic hypertension while taking two or more antihypertensive medications or chronic kidney disease. Using concealed allocation, patients were randomized to receive stenting plus medical therapy or medical therapy alone. Medical management included antiplatelet agents, antihypertensives, and lipid-lowering therapies. Specifically, all patients received candesartan (Atacand) with or without hydrochlorothiazide, as well as the combination pill amlodipine/atorvastatin (Caduet). Diabetes was managed according to clinical practice guidelines. The two groups had similar comorbidities at baseline. Overall, 90% of patients in each group had hyperlipidemia and approximately 30% had diabetes. The primary outcome was a composite of death from cardiovascular or renal causes, stroke, myocardial infarction, hospitalization for acute heart failure, worsening renal insufficiency, or the need for permanent dialysis. At a median follow-up of 43 months, there was no significant difference detected between the two groups in the composite outcome (hazard ratio = 0.95; 95% confidence interval, 0.76 to 1.17) or its individual components. All-cause mortality was also similar (hazard ratio = 0.80; 95% confidence interval, 0.58 to 1.12).

Study design: Randomized controlled trial (nonblinded)

Funding source: Industry plus government

Allocation: Concealed

Setting: Outpatient (any)

Reference: CooperCJMurphyTPCutlipDEet alCORAL InvestigatorsStenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med.2014; 370( 1): 13– 22.