Do patients undergoing renal revascularization outside of the ASTRAL trial show any benefit? Results of a single centre observational study

Introduction/objectives. Though recent research has concluded that revascularizationof atherosclerotic renal artery stenosishas no benefit for most patients, negative findings of the Angioplasty and STent for Renal Artery Lesions (ASTRAL) trial have been criticized in professional fora. Aim of the current study was to determine whether patients undergoing renal revascularizationoutside of ASTRAL showed any benefit. If so, could we determine a patient group that would benefit from intervention? Methods. Patients undergoing renal revascularizationoutside of the ASTRAL trial between 2003 and 2007 at our institution were reviewed. The primary comparison was the rate of decline of renal function based on individual reciprocal creatinine plots for the periods leading up to and following revascularization. Those who showed any improvement in the mean slope were compared to those with a negative or neutral response. Results. One hundred and twenty-seven patients underwent renal revascularizationoutside of ASTRAL. The majority [79 (62%)] showed some improvement in the rate of change in renal function, though overall this failed to reach statistical significance. Those who responded positively tended to be declining faster prior to intervention; they were less likely to require RRT (6 versus 29%), and if they did, it was significantly later (3.6 versus 0.7 years). Mortality was, however, similar in both groups. Subgroup analysis was undertaken of patients in whom kidney function was rapidly deteriorating prior to revascularization. The rate of change in this group showed a more sizeable improvement (P = 0.05). Nonetheless, a similar proportion of both groups required RRT and there was no evidence of improvement in overall mortality. Conclusions. In keeping with ASTRAL’s findings, our use of renal revascularizationhas produced no demonstrable benefit overall. There was a suggestion of benefit in patients with rapidly declining renal function in terms of delaying the need for renal replacement therapy, but improvements in cardiovascular outcomes have yet to be proven.