动脉粥样硬化性肾动脉狭窄的发生率及预测因素研究——126例冠脉造影患者临床分析
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摘要
目的：在诊断或疑诊冠心病的动脉造影患者中观察动脉粥样硬化性肾动脉狭窄(atherosclerotic renal artery stenosis,ARAS)的发生率，了解肾动脉狭窄的发生程度和病变部位的分布情况，寻找及早识别ARAS发生的高危因素。
方法：在2002年10月至2003年11月诊断或疑诊冠心病的住院患者中同时行冠状动脉、肾动脉造影。行动脉造影前采集患者病史和血标本。采用Seldinger技术、Judkins法行冠状动脉、肾动脉造影。以高血压、吸烟、糖尿病、性别、年龄、心衰、周围血管病变、高血脂、肾功能不全为自变量，肾动脉狭窄(renal artery stenosis,RAS)为因变量行单变量Logistic回归分析，再以分析结果有统计学意义的变量为自变量，行多变量Logistic回归分析。P＜0.05及以上为相差显著。
结果：13个月收集了126例临床资料，患者平均年龄63.18±9.53岁，其中男82人(65.1％)，女44人(34.9％)。共24人有肾动脉病变，占总数的19.04％，13人有明显肾动脉狭窄，占10.32％；单侧肾动脉20例占15.87％，双侧狭窄4例占3.17％；其中肾动脉开口处狭窄为60.7％
重庆医科大学硕士研究生论文
(17例)，’肾动脉主干狭窄为35.7%(10例)，肾动脉分支病变狭窄为
3.57%(1例);行单变量、多变量Logistic回归分析，有统计学意义因
素为:吸烟(OR== 1 .26，p=0.044)、冠脉病变(oR=1.91，p=0.003)、高脂血
症(OR= 1 .96，p=0.001)、冠脉病变(coron娜arte叮disease，eAD)中的三
支病变(OR井1.13，P=0.045)。
结论:(l)在中老年疑诊或诊断冠心病行动脉造影患者中，ARAs的
发生率为19.04%，其狭窄部位多见于肾动脉开口处。(2) ARAs存在的
高危因素有冠脉病变、外周血管病变、吸烟、高血脂、肾功能不全，
其独立预测因素为高血脂、冠脉病变、吸烟。(3)冠脉病变中有三支病
变者与ARAS并存的相关性大。
Objective: Prevalence of atherosclerotic renal artery stenosis (ARAS) were studied in Patients with coronary artery disease or suspected coronary by angiography, then the degree and location of renal artery stenosis(RAS) were screened, and risk factors of ARAS were identify as early.
Methods: 129 patients were studied from October 2002 and Novenber 2003. Patients' data and blood samples were collected before cardiac catherization and renal artery angioplasty were performed. Coronary artery angiography and renal arteriography performed by Seldinger and Judkins technique. Independent variables included hypertesion, smoking ,
congestive heart failure , diabetes mellitus, age, peripheral vascular disease, serum creatinine, blood cholesterin and glycerin, and dependent variable was RAS. The significant variables in the univariate model were then analyzed in multivariate logistic regression model to identify the best set of independent predictors of RAS.Statistical significance was defined as P<0.05.
Results: 126 patients' mean age were 63.18 +9.53(82 males,44 females).24(19.04%) had ARAS, 13(10.32%) had significant RAS (,50%), Significant unilateral stenosis was 15.87% and bilateral stenosis was 3.17% of the total patients.The ostial lesions was 60.7% ,the main stem was 35.7% and the branch was 3.57% of 28 renal artery stenosis.By univariate and multivariate logistic regression analysis, predictors included smoking(OR=1.26,P=0.044), coronary artery disease(OR=1.91,P=0.003), hyperlipidemia (OR=1.96,P=0.001), triple coronary artery diseases (OR=1.13,P=0.048).
Conclusion: (1) The prevalence of atherosclerotic renal artery stenosis is 19.04% in a patient population undergoing cardiac catheterization, RAS is more commom in the ostial sites. (2) Risk factors of ARAS existencing are smoking , coronary artery disease , peripheral vascular disease , hyperlipidemia , renal insufficience, and independent predictors are smoking , coronary artery disease and hyperlipidemia.(3) There is
significant correlation between triple vessel diseases of CAD and the presence of ARAS.
方法：在2002年10月至2003年11月诊断或疑诊冠心病的住院患者中同时行冠状动脉、肾动脉造影。行动脉造影前采集患者病史和血标本。采用Seldinger技术、Judkins法行冠状动脉、肾动脉造影。以高血压、吸烟、糖尿病、性别、年龄、心衰、周围血管病变、高血脂、肾功能不全为自变量，肾动脉狭窄(renal artery stenosis,RAS)为因变量行单变量Logistic回归分析，再以分析结果有统计学意义的变量为自变量，行多变量Logistic回归分析。P＜0.05及以上为相差显著。
结果：13个月收集了126例临床资料，患者平均年龄63.18±9.53岁，其中男82人(65.1％)，女44人(34.9％)。共24人有肾动脉病变，占总数的19.04％，13人有明显肾动脉狭窄，占10.32％；单侧肾动脉20例占15.87％，双侧狭窄4例占3.17％；其中肾动脉开口处狭窄为60.7％
重庆医科大学硕士研究生论文
(17例)，’肾动脉主干狭窄为35.7%(10例)，肾动脉分支病变狭窄为
3.57%(1例);行单变量、多变量Logistic回归分析，有统计学意义因
素为:吸烟(OR== 1 .26，p=0.044)、冠脉病变(oR=1.91，p=0.003)、高脂血
症(OR= 1 .96，p=0.001)、冠脉病变(coron娜arte叮disease，eAD)中的三
支病变(OR井1.13，P=0.045)。
结论:(l)在中老年疑诊或诊断冠心病行动脉造影患者中，ARAs的
发生率为19.04%，其狭窄部位多见于肾动脉开口处。(2) ARAs存在的
高危因素有冠脉病变、外周血管病变、吸烟、高血脂、肾功能不全，
其独立预测因素为高血脂、冠脉病变、吸烟。(3)冠脉病变中有三支病
变者与ARAS并存的相关性大。
Objective: Prevalence of atherosclerotic renal artery stenosis (ARAS) were studied in Patients with coronary artery disease or suspected coronary by angiography, then the degree and location of renal artery stenosis(RAS) were screened, and risk factors of ARAS were identify as early.
Methods: 129 patients were studied from October 2002 and Novenber 2003. Patients' data and blood samples were collected before cardiac catherization and renal artery angioplasty were performed. Coronary artery angiography and renal arteriography performed by Seldinger and Judkins technique. Independent variables included hypertesion, smoking ,
congestive heart failure , diabetes mellitus, age, peripheral vascular disease, serum creatinine, blood cholesterin and glycerin, and dependent variable was RAS. The significant variables in the univariate model were then analyzed in multivariate logistic regression model to identify the best set of independent predictors of RAS.Statistical significance was defined as P<0.05.
Results: 126 patients' mean age were 63.18 +9.53(82 males,44 females).24(19.04%) had ARAS, 13(10.32%) had significant RAS (,50%), Significant unilateral stenosis was 15.87% and bilateral stenosis was 3.17% of the total patients.The ostial lesions was 60.7% ,the main stem was 35.7% and the branch was 3.57% of 28 renal artery stenosis.By univariate and multivariate logistic regression analysis, predictors included smoking(OR=1.26,P=0.044), coronary artery disease(OR=1.91,P=0.003), hyperlipidemia (OR=1.96,P=0.001), triple coronary artery diseases (OR=1.13,P=0.048).
Conclusion: (1) The prevalence of atherosclerotic renal artery stenosis is 19.04% in a patient population undergoing cardiac catheterization, RAS is more commom in the ostial sites. (2) Risk factors of ARAS existencing are smoking , coronary artery disease , peripheral vascular disease , hyperlipidemia , renal insufficience, and independent predictors are smoking , coronary artery disease and hyperlipidemia.(3) There is
significant correlation between triple vessel diseases of CAD and the presence of ARAS.
引文
1. Safian RD, Textor SC. Renal-artery stenosis. N Engl J Med. 2001; 344:431-442.
2. Crowley JJ, Santos RM, Peter RH, et al. Progression of renal artery stenosis in patients undergoing cardiac catheterization. Am Heart J 1998; 136:913-918.
3. Schreiber M J, Pohl MA, Novick AC. The natural history of atherosclerotic and fibrous renal artery disease. Urol Clin North Am 1984; 11: 383-392.
4. Picketing TG; Herman L,Devereux RB,et al.Recurrent pulmonary oedema in hypertension due to bilateral renal artery sternosis:treatment by angioplasty or syrgical revascularisation.Lancet, 1988,2:551-2.
5. Pimentel JL,Sundell CL,Wang S,et al.Role of angiotension Ⅱ in the expression and regulation of transforming growth factor-beta in obstractive nephropathy. Kidney Int 1995; 51:1481-6.
6. Textor SC, Novick A, Tarazi RC, et al.Critical perfusion pressure for renal function in patients with bilateral atherosclerotic renal vascular disease.Ann Int Med 1985;102:309-14.
7. Dean RH, Tribble RW, Hansen K J, et al. Evolution of renal insufficiency in ischemic nephropathy. Ann Surg 1991; 213:446-455.
8. Johansson M, Herlitz H, Jensen G, Rundqvist B, Ftiberg P: Increased cardiovascular mortality in hypertensive patients with renal artery stenosis. Relation to sympathetic activation, renal function and treatment regimens. Hypertens J, 1999,17:1743 -50.
9. Ramos F, Kotliar C, Alvarez D, et al.renal function and outcome of PTRA and stenting for atherosclerotic renal artery stenosis. Kidney Int.2003.63(10:27
10. Libertino JA, Bosco P J, Ying CY, et al. Renal revascularization to preserve and restore renal function. J Urol 1992; 147:1485-1487.
11. Hyun YS, Jae HH, Hyunjin N,et al.The prevalence and associated risk factors of
renal artery stenosis in patients undergoing cardiac catheterization.Yonsei medical J,2000,2:219-25.
12. Hoim EA, Randlov A, Strandgaard S.Brief report:acute renal failure after losartan treatement in a patient with bilateral renal artery stenosis.Blood Pressure 1996;5:360-2.
13. Uzu T, Inoue T, Fujii T, rt al.Prevalence and predictors of Renal artery stenosis in patients with myocardial infaction.Am J Kidney Dis,1997,29:733-8.
14. Harding MB, Smith LR, Himmelstein SI,et al. Renal artery stenosis: prevalence and assosiated risk factors in patients undergoing crouting cardiac cathetedzation.J Am Soc Nephrol, 1992,2,1606-8.
15. Rath PC, Agarwala MK,Dhar PK, et al. Renal artery involvement in patients of coroartery disease undergoing coronary angiograp prospective study.J Assoc Physicians Indian,2002,50,523-6.
16．杨进刚、胡大一、刘坤申等．冠状动脉造影患者中肾动脉狭窄的发生率．中华内科杂志，2002，41：24-7．
17. Alhaddad IA, Blum S, Heller EN,et al.Renal artery stenosis in minority patients undergoing diagnostic cardiac catheterization:prevalence and risk factors.J Cardiovasc Pharmatol Ther,2001,6(2):4147-53.
18. Pillay WR, Kan YM, Cfinnion JN,et al.Prospectine multientre study of the natural history of atherosclerotic renal artery stenosis in patients with peripheral vascular disease,Br J Sury,2001,89(6):737-40.
19. Bloch MJ, Trost DW, Picketing TG, Sos TA, August P. Prevention of recurrent pulmonary edema in patients with bilateral renovascular disease through renal artery stent placement. Am J Hypertens 1999; 12(1 pt 1): 1-7.
20. Sawicki PT, Kaiser S, Heinemann L,et al.Precalence of renal artery stenosis in diabetes mellitus-an autopsy study.J inter Med,1991,229(6):489-92.
21. Mailloux LU, Bellucci AG, Mossey RT, et al. Predictors of survival in patients undergoing dialysis. Am J Med 1988;84:855-862.
22. Hricik DE, Browning PJ, Kopelman R, Goomo WE, Madias NE, Dzau VJ. Captopril-induced functional renal insufficiency in patients with bilateral renal-artery stenoses or renal-artery stenosis in a solitary kidney. N Engl J Med 1983;308:373-376.
23. van Rooden C J, van Bockel JH, De Backer GG, Hermans J, Chang PC. Long-term outcome of surgical revascularization in ischemic nephropathy: normalization of average decline in renal function. J Vasc Surg 1999; 29: 1037-1049.
24. Watson PS, Hadjipetrou P, Cox SV, Piemonte TC, Eisenhauer AC. Effect of renal artery stenting on renal function and size in patients with atherosclerotic renovascular disease. Circulation 2000; 102:1671-1677.
25．毕增褀、郑法雷．慢性缺血性肾病的临床表现与主要病理生理改变．中华内科杂志，2002．39：418-20．
26. Shanley PE.The pathology of chronic renal ischemia. Semin Neprol 1996; 16:21-32.
27. Barri YM, Davidson RA, Senler S, et al. Prediction of cure of hypertension in atherosclerotic renal artery stenosis. South Med J 1996; 89: 679—683.
28. Alejandro R, Chade MD, Martin Rodrignez-Porcet MD,et al.Distinct renal injury in early atherosclerosis and renovascular disease.Circulation,2002,106.1165-6.
2. Crowley JJ, Santos RM, Peter RH, et al. Progression of renal artery stenosis in patients undergoing cardiac catheterization. Am Heart J 1998; 136:913-918.
3. Schreiber M J, Pohl MA, Novick AC. The natural history of atherosclerotic and fibrous renal artery disease. Urol Clin North Am 1984; 11: 383-392.
4. Picketing TG; Herman L,Devereux RB,et al.Recurrent pulmonary oedema in hypertension due to bilateral renal artery sternosis:treatment by angioplasty or syrgical revascularisation.Lancet, 1988,2:551-2.
5. Pimentel JL,Sundell CL,Wang S,et al.Role of angiotension Ⅱ in the expression and regulation of transforming growth factor-beta in obstractive nephropathy. Kidney Int 1995; 51:1481-6.
6. Textor SC, Novick A, Tarazi RC, et al.Critical perfusion pressure for renal function in patients with bilateral atherosclerotic renal vascular disease.Ann Int Med 1985;102:309-14.
7. Dean RH, Tribble RW, Hansen K J, et al. Evolution of renal insufficiency in ischemic nephropathy. Ann Surg 1991; 213:446-455.
8. Johansson M, Herlitz H, Jensen G, Rundqvist B, Ftiberg P: Increased cardiovascular mortality in hypertensive patients with renal artery stenosis. Relation to sympathetic activation, renal function and treatment regimens. Hypertens J, 1999,17:1743 -50.
9. Ramos F, Kotliar C, Alvarez D, et al.renal function and outcome of PTRA and stenting for atherosclerotic renal artery stenosis. Kidney Int.2003.63(10:27
10. Libertino JA, Bosco P J, Ying CY, et al. Renal revascularization to preserve and restore renal function. J Urol 1992; 147:1485-1487.
11. Hyun YS, Jae HH, Hyunjin N,et al.The prevalence and associated risk factors of
renal artery stenosis in patients undergoing cardiac catheterization.Yonsei medical J,2000,2:219-25.
12. Hoim EA, Randlov A, Strandgaard S.Brief report:acute renal failure after losartan treatement in a patient with bilateral renal artery stenosis.Blood Pressure 1996;5:360-2.
13. Uzu T, Inoue T, Fujii T, rt al.Prevalence and predictors of Renal artery stenosis in patients with myocardial infaction.Am J Kidney Dis,1997,29:733-8.
14. Harding MB, Smith LR, Himmelstein SI,et al. Renal artery stenosis: prevalence and assosiated risk factors in patients undergoing crouting cardiac cathetedzation.J Am Soc Nephrol, 1992,2,1606-8.
15. Rath PC, Agarwala MK,Dhar PK, et al. Renal artery involvement in patients of coroartery disease undergoing coronary angiograp prospective study.J Assoc Physicians Indian,2002,50,523-6.
16．杨进刚、胡大一、刘坤申等．冠状动脉造影患者中肾动脉狭窄的发生率．中华内科杂志，2002，41：24-7．
17. Alhaddad IA, Blum S, Heller EN,et al.Renal artery stenosis in minority patients undergoing diagnostic cardiac catheterization:prevalence and risk factors.J Cardiovasc Pharmatol Ther,2001,6(2):4147-53.
18. Pillay WR, Kan YM, Cfinnion JN,et al.Prospectine multientre study of the natural history of atherosclerotic renal artery stenosis in patients with peripheral vascular disease,Br J Sury,2001,89(6):737-40.
19. Bloch MJ, Trost DW, Picketing TG, Sos TA, August P. Prevention of recurrent pulmonary edema in patients with bilateral renovascular disease through renal artery stent placement. Am J Hypertens 1999; 12(1 pt 1): 1-7.
20. Sawicki PT, Kaiser S, Heinemann L,et al.Precalence of renal artery stenosis in diabetes mellitus-an autopsy study.J inter Med,1991,229(6):489-92.
21. Mailloux LU, Bellucci AG, Mossey RT, et al. Predictors of survival in patients undergoing dialysis. Am J Med 1988;84:855-862.
22. Hricik DE, Browning PJ, Kopelman R, Goomo WE, Madias NE, Dzau VJ. Captopril-induced functional renal insufficiency in patients with bilateral renal-artery stenoses or renal-artery stenosis in a solitary kidney. N Engl J Med 1983;308:373-376.
23. van Rooden C J, van Bockel JH, De Backer GG, Hermans J, Chang PC. Long-term outcome of surgical revascularization in ischemic nephropathy: normalization of average decline in renal function. J Vasc Surg 1999; 29: 1037-1049.
24. Watson PS, Hadjipetrou P, Cox SV, Piemonte TC, Eisenhauer AC. Effect of renal artery stenting on renal function and size in patients with atherosclerotic renovascular disease. Circulation 2000; 102:1671-1677.
25．毕增褀、郑法雷．慢性缺血性肾病的临床表现与主要病理生理改变．中华内科杂志，2002．39：418-20．
26. Shanley PE.The pathology of chronic renal ischemia. Semin Neprol 1996; 16:21-32.
27. Barri YM, Davidson RA, Senler S, et al. Prediction of cure of hypertension in atherosclerotic renal artery stenosis. South Med J 1996; 89: 679—683.
28. Alejandro R, Chade MD, Martin Rodrignez-Porcet MD,et al.Distinct renal injury in early atherosclerosis and renovascular disease.Circulation,2002,106.1165-6.