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Background: Takayasu arteritis is a rare large-vessel vasculitis that predominantly affects females of Asian descent. This retrospective analysis was performed to increase understanding of the epidemiology of the disease in the United States.Methods: We performed a retrospective cohort study in 2 tertiary centers. Patients were selected according to the American College of Rheumatology classification criteria for Takayasu arteritis. Data collected included demographic characteristics and details of physical examinations, treatments, and surgical interventions. Data were managed with REDCap (Research Electronic Data Capture) tools.Results: The study included 57 patients. The female:male ratio was 4.2:1, the median age at diagnosis was 29 years, 61.4% of the patients were Caucasians, and 86% of the patients had stenosis on imaging. Hata V was the most common angiographic classification (37.5% of patients). Vascular interventions were required in 43.9% of patients. The most frequent complications were hypertension (56.1%), renal artery stenosis (28.1%), and aortic insufficiency (19.3%).Conclusions: Takayasu arteritis continues to be a rare large-vessel vasculitis. In the United States, it tends to affect predominantly Caucasian females, with cervicobrachial involvement. This cohort reflects the morbidity, multiple interventions, and complications experienced by patients with Takayasu arteritis. [ABSTRACT FROM AUTHOR]

The aim of this paper is to comprehensively analyze the literature focused on frequency of the presence of the accessory renal arteries in the human body. A systematic analysis of papers has been made. With regard to ethnicity, the incidence of accessory renal arteries fluctuates from 4% in a Malaysian population to 61.5% in a Brazilian population. The frequency is lowest in eastern and southern Asia (from 4% to 18.4%). In some, not ethnically homogenous populations, wide span of occurrence of accessory renal arteries is described (e.g. American - averaging from 18% to 28.8%). A higher frequency of accessory renal arteries was observed in fetuses compared to adults. Moreover, differences in the presence and number of accessory renal arteries reported in different papers are a consequence of type of visualizing technique used in research - especially when computed tomography and anatomical dissection were compared. The increasing number of surgical interventions, especially where laparoscopic methods are concerned, underlines the importance of such knowledge especially to surgeons, interventional radiologists, nephrologists, and vascular surgeons. [ABSTRACT FROM AUTHOR]

Introduction: This study compared aortorenal bypass to renal artery stenting to determine the most efficacious and financially sound method for treating patients with atherosclerotic renal artery stenosis (RAS).Methods: A decision analysis using direct and indirect costs, and value of statistical life (VSL) was completed. Direct costs were obtained using the Nationwide Inpatient Sample (NIS), indirect costs from the National Institute of Diabetes and Digestive and Kidney Diseases, and VSL from the Department of Transportation. A variance-based sensitivity analysis was completed to assess the accuracy of the decision analysis.Results: Aortorenal bypass has a 95% five-year patency, a 98% 30-day survival, a 26% rate of overall complications, and a 70% five-year dialysis-free survival. Renal artery stenting has a 56% five-year patency, a 99% 30-day survival, a 40% rate of complications, and a 65% five-year dialysis-free survival. Renal artery stenting has an overall cost of $305,370 and aortorenal bypass has an overall cost of $103,453 per patient. After accounting for VSL, renal artery stenting has a negative value of -$182,270 and aortorenal bypass has a value of $415,881.Conclusions: Lower five-year patency and higher rate of complications from renal artery stenting that ultimately lead to significantly lower five-year dialysis-free survival. [ABSTRACT FROM AUTHOR]

The article discusses the study which examines the effects of urocortin 2 (Unc2) and diuretics on renal function and the renin-angiotensen-aldosterone system of patients with heart failure in the U.S. It notes that the agents would be used in conjunction with standard diuretic therapy. It mentions that the study reveals that Ucn2 therapy with diuretics is beneficial for patients with heart failure.

The past decade has witnessed an evolution of the specialty of Nephrology in the United States to an interventional discipline. Traditionally, Interventional Nephrologists have focused on the venous side of an arteriovenous access. However, these specialists are beginning to include arterial disease related to renal patients under the purview of this specialty. Recent data have emphasized that inflow stenosis of an arteriovenous access frequently results in vascular access dysfunction. Peripheral vascular disease, resulting in distal hypoperfusion ischemia syndrome of the hand bearing the access, is similarly being recognized and managed more frequently by these experts. Two distinct entities, subclavian artery and renal artery stenosis, are also being addressed by interventional nephrologists. This article focuses on arterial interventions performed by interventional nephrologists and describes the epidemiology, techniques, and outcomes of arterial intervention as they relate to the care of patients with hemodialysis access and chronic kidney disease. [ABSTRACT FROM AUTHOR]

While African Americans in the United States are disproportionately affected by HIV, they are less likely to take antiretroviral therapies. Different first-line antiretroviral therapies are associated with short-term and long-term adverse event (AE) risks. We estimated the willingness of antiretroviral-naïve, HIV-positive African Americans to accept risks of acute AEs with known outcomes and long-term AEs with uncertain outcomes in exchange for virologic suppression. We estimated the relative importance of short-term and long-term AE risks. Two hundred thirty-five subjects were recruited through eight clinics in the United States. One hundred fifty-eight subjects met study inclusion criteria. One hundred fifty-three subjects completed a series of choice-format conjoint trade-off tasks. In each task, subjects were asked to choose between two hypothetical treatments with varying levels of virologic failure, risks of hypersensitivity reaction, decreases in bone mineral density (BMD), and renal impairment, and outcome uncertainty associated with the risks of decreased BMD and renal impairment. Attributes were expressed as probabilities of occurrence. We calculated the relative importance of each AE and the level of risk subjects would accept to reduce the risk of virologic failure. Subjects indicated that short-term AEs with relatively certain outcomes are preferred to long-term AEs with uncertain outcomes. Subjects were strongly averse to the risk of decreased BMD that could not be treated successfully or when the outcome was uncertain and to the risk of renal impairment that could not be treated successfully. Subjects were willing to accept increased risks of AEs in exchange for lower risk of virologic failure. [ABSTRACT FROM AUTHOR]

Background: The mortality rate for renal artery bypass grafting (RABG) is reported to be 0% to 4% for patients with renovascular hypertension and 4% to 7% for patients with ischemic nephropathy. However, these data come from high-volume referral centers known for their expertise in treating these conditions. Because of the relative infrequency of these operations in most vascular surgery practices, the nationwide outcomes for RABG are not known. The purpose of this study was to define the operative mortality rate for RABG in the United States and to identify risk factors for perioperative mortality. Methods: The National Inpatient Sample was analyzed to identify patients undergoing RABG for the years 2000 to 2004. Categoric data were analyzed using χ2 and the Cochran-Armitage trend tests. Multivariate logistic regression analyses were performed to identify risk factors for perioperative mortality after RABG. Results: During the study period, 6608 patients underwent RABG, representing a frequency of 3.51 operations per 100,000 discharges. More than two-thirds were performed at teaching hospitals (4564 vs 2,044; P < .0001). The frequency of RABG decreased by 30.7% between 2000 and 2004 (4.28 vs 2.96 RABGs per 100,000 discharges; P for trend < .0001). The in-hospital mortality for RABG was 10.0%. On univariate analysis, in-hospital mortality after RABG varied with increasing age, race, region of the country, and a preoperative history of chronic renal failure, congestive heart failure, or chronic lung disease. Logistic regression models identified advanced age (odds ratio [OR] 1.57; 95% confidence interval [CI], 1.44-1.72], female gender (OR, 1.20; 95% CI, 1.02-1.41), and a history of chronic renal failure (OR, 2.21; 95% CI, 1.75-2.78), congestive heart failure (OR, 1.94; 95% CI, 1.44-2.62), or chronic lung disease (OR, 1.40; 95% CI, 1.18-1.67) as independent markers of risk-adjusted, in-hospital mortality (P < .0001 for each of these five variables). Conclusions: Nationwide in-hospital mortality after RABG is higher than predicted by prior reports from high-volume referral centers. Advanced age, female gender, and a history of chronic renal failure, congestive heart failure, or chronic lung disease were predictive of perioperative death. For the typical vascular practice, these data may provide a rationale for lower risk alternatives, such as renal artery stenting or referral to high-volume referral centers for RABG. [Copyright &y& Elsevier]

Despite proven renoprotection from RAAS blockade and its increased application since the early 1990s, we have experienced an increasing CKD/ESRD epidemic, especially among U.S. diabetics. Consequently, some concerns regarding iatrogenic azotemia from RAAS blockade have surfaced. We hypothesized that susceptible CKD patients with normal renal arteries on conventional angiography, including MRA, but who have microvascular arteriolar narrowing in the renal circulation - mimicking large vessel renal artery stenosis, even without precipitating risk factors - could experience worsening azotemia after periods of time exceeding three months on stable doses of RAAS blockade. Between September 2002 and February 2005, as part of a larger prospective study of renal failure in CKD patients on RAAS blockade, we studied five patients with >25% higher serum creatinine and normal MRA without precipitating factors. RAAS blockade was discontinued. eGFR by MDRD was monitored. Five Caucasians (M:F = 1:4; age 68 years) were enrolled and followed-up at 29.6 months. The duration of RAAS blockade at enrollment was 34.6 months. The baseline eGFR had decreased from 28.4 ± 7.1 to 17.0 ± 7.4 ml/min/1.73 m2 BSA (p < 0.001) at enrollment. One required temporary hemodialysis; no deaths occurred. eGFR increased from 17.0 ± 7.4 to 24.6 ± 9.5 ml/min/1.73 m2 BSA (p = 0.009), 29.6 (20-43) months after stopping the RAAS blockade. We conclude that worsening azotemia occurs in susceptible CKD patients on stable doses of RAAS blockade after long periods of time, despite normal renal arteries without precipitating risk factors. We submit that microvascular renal arteriolar narrowing is the pathophysiologic mechanism. These observations call for further study. [ABSTRACT FROM AUTHOR]

Chuang P, Parikh CR, Langone A. Urinary tract infections after renal transplantation: a retrospective review at two US transplant centers.Clin Transplant 2005 DOI: 10.1111/j.1399-0012.2005.00327.x© Blackwell Munksgaard, 2005Urinary tract infections (UTIs) are the most common infectious complication following renal transplantation. Previous studies uniformly report that renal transplant recipients develop UTIs more often than the general population, but widely differ on how frequently UTIs occur after transplantation. These studies also disagree on the risk factors associated with developing post-transplant UTIs, as well as the effect that UTIs may have on graft outcomes and patient mortality. We performed a retrospective cohort study including all the adult patients who received a renal transplant at two US transplant centers from January 1996 to December 2002 (500 patients). Two hundred and thirteen (43%) patients developed one or more post-transplant UTIs over a mean follow-up period of 42 months. Significant risk factors for post-transplant UTIs were advanced age, female gender, reflux kidney disease, use of azathioprine and cadaveric donor. UTIs did not increase risk for renal graft loss, but were associated with increased mortality (3.5 odds ratio, 95% confidence interval 1.68–7.23). We conclude UTIs may be associated with an increased mortality risk in renal transplant recipients. Prevention of UTIs in high-risk renal transplant patients or those with recurrent UTIs may possibly decrease post-transplant mortality. [ABSTRACT FROM AUTHOR]

Objective: Fibromuscular Dysplasia (FMD) is a rare non-atherosclerotic non-inflammatory vascular disease associated with arterial aneurysms and dissections. The epidemiology of FMD is not well understood. We sought to characterize the epidemiology of FMD utilizing a large aggregated electronic medical record database., Methods: We used a commercial database (Explorys, IBM Watson), which aggregates data from electronic health records from 26 major integrated healthcare systems in the United States. Fibromuscular dysplasia cases were identified using a unique systemized nomenclature of medical terminology (SNOMED CT) term. We calculated the overall and age-, race-, and sex-based prevalence of FMD, and evaluated sex and race-specific differences in manifestations., Results: A total of 40,566,670 individuals were active in the database from January 2015 to January 2020. Of these, 4860 had a diagnosis of FMD with an overall prevalence of 12.0 cases per 100,000 individuals. The majority of patients with FMD were female (n=4130, 85.0%), Caucasian (n=3960, 80.5%) and adults aged 18 to 65 years (n=2610, 53.7%). FMD was more common in women (prevalence 18.4 per 100,000) than men (4.0 per 100,000) and among Caucasians (15.8 per 100,000) than African Americans (11.2 per 100,000). Men and African Americans with FMD were more likely to have traditional atherosclerotic risk factors (hypertension, diabetes mellitus type 2, smoking, obesity, hyperlipidemia, chronic kidney disease), and vascular manifestations (stroke, renal infarction, claudication), compared with women and Caucasians. Men with FMD were more likely to have dissection of aorta and renal artery as well as aneurysm of vertebral artery, coronary artery, aorta and iliac artery. African-Americans were more likely to have ruptured aortic aneurysms than Caucasians., Conclusions: The overall prevalence of FMD in this large aggregated electronic medical record study is estimated at 12.0 per 100,000 persons. FMD is more common in women and Caucasians, with variable characteristics and manifestations., Competing Interests: Declaration of Competing Interest There are no potential conflicts (financial, professional, or personal) to disclose by the other authors (Mariam Nadeem Rana, MD, Sadeer Al-Kindi, MD)., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to investigate bipolar radiofrequency renal denervation in patients with hypertension not receiving medications at baseline., Background: A blood pressure-reducing effect of renal denervation has been difficult to isolate in clinical investigations., Methods: REDUCE HTN: REINFORCE (Renal Denervation Using the Vessix Renal Denervation System for the Treatment of Hypertension) was a randomized, sham-controlled multicenter trial. Patients with office systolic blood pressure (SBP) of 150 to 180 mm Hg and average 24-h ambulatory SBP of 135 to 170 mm Hg after medication washout underwent bipolar radiofrequency renal denervation or a sham procedure. The planned outcome was 8-week change in 24-h ambulatory SBP. Enrollment was terminated for apparent futility before a sufficient sample for powered efficacy comparisons was enrolled. Safety assessments included all-cause death, renal failure, severe hypotension or syncope, hypertensive crisis, and renal artery stenosis., Results: Baseline 24-h blood pressure was 148.3 ± 10.9/85.7 ± 9.1 mm Hg for the denervation group (n = 34, mean age 58.5 ± 10.1 years, 47% women) and 149.1 ± 7.2/86.4 ± 9.8 mm Hg for the control group (n = 17, mean age 58.2 ± 9.8 years, 24% women). At 8 weeks, mean 24-h SBP reductions for the renal denervation and control groups were -5.3 mm Hg (95% confidence interval [CI]: -8.8 to -1.8 mm Hg) and -8.5 mm Hg (95% CI: -13.3 to -3.8 mm Hg), respectively (difference 3.3 mm Hg; 95% CI: -2.8 to 9.3 mm Hg; p = 0.30). Antihypertensive medications could then be added. By 6 months, decreases in SBP were greater for the denervation group, yielding between-group differences of -7.2 mm Hg (95% CI: -15.2 to 0.8 mm Hg; p = 0.08), -9.7 mm Hg (95% CI: -17.7 to -1.7 mm Hg; p = 0.02), and -11.4 mm Hg (95% CI: -19.2 to -3.7 mm Hg; p < 0.01) for 24-h, daytime ambulatory, and office measurements, respectively. Through 12 months, 1 patient (renal denervation group) had a hypertensive urgency requiring immediate management, and 1 experienced progression of renal artery stenosis., Conclusions: Future studies of radiofrequency renal denervation must anticipate delayed treatment effects. (Renal Denervation Using the Vessix Renal Denervation System for the Treatment of Hypertension [REDUCE HTN: REINFORCE]; NCT02392351)., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Renal artery calcium (RAC) has been linked to several cardiovascular disease (CVD) risk factors, including age, male gender, and hypertension. The purpose of this study was to determine whether anthropometric measures of obesity are associated with presence of RAC., Methods: We studied 1287 community-dwelling adults enrolled in the Multi-Ethnic Study of Atherosclerosis. Logistic regression models adjusted for CVD risk factors were used to examine body mass index (BMI), waist circumference (WC), hip circumference (HC), and waist-to-hip ratio (WHR) as primary predictors of RAC., Results: Study participants had a mean age of 67.7 years, 55.7% were female, and 36.8% were non-Hispanic White. Prevalence of RAC was 33.3%. WC and WHR as continuous variables were not significant with adjustment. Subjects with high WC, as defined by World Health Organization cut-offs, had significantly higher odds for RAC in the fully adjusted model. BMI and HC were not significantly associated with RAC in any models., Conclusions: In this community-based sample of older adults, higher levels of WC are significantly associated with RAC independently of CVD risk factors. Adults who meet World Health Organization criteria for high WC may be at higher risk for complications of calcified atherosclerosis in the renal arteries., (Copyright © 2018 Elsevier B.V. All rights reserved.)

The article focuses on a science advisory on the indications for renal arteriography published by the American Heart Association (AHA). It is vital that the risks and costs of screening for atheroschlerotic renal artery stenosis must be weighed against the benefits. It is reasonable to perform diagnostic screening renal arteriography during cardiac catheterization when a patient is at risk of atherosclerotic renal artery stenosis and is a candidate for revascularization according to AHA.

Hemorrhagic deaths of living kidney donors from failure of vascular clips used on the renal artery, first documented in 2006, have continued due to postoperative Hem-o-lok clip failure with sudden, massive bleeding. While the FDA issued a Class II recall of the Hem-o-lok clip for laparoscopic donor nephrectomies in 2006, two live kidney donors in the United States and one in India have since died. Compliance in timely reporting of deaths by the manufacturer and donor hospitals has not been enforced. Oversight agencies did not inform practitioners that donors died due to clip failures. A February 2011 survey disclosed that Hem-o-lok or other clips are still used by some surgeons as a sole means of arterial control in laparoscopic donor nephrectomy; thus, a practice with documented fatal outcomes persists. We conclude that systems failures by oversight-regulatory agencies in communication to active clinicians led, at least in part, to preventable deaths. Information which was disseminated was neither complete nor timely. A corrective plan, funded by oversight agencies and the Hem-o-lok manufacturer, is proposed. All surgeons operating on a living organ donor must select vascular control techniques that entail tissue transfixion and assure a safe operative recovery. The Hem-o-lok and other surgical clips must not be used to control the donor renal artery., (© Copyright 2012 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Improved technology for detection of and endovascular procedures for renal artery stenosis due to atherosclerosis has been associated with increases in renal artery intervention. Hypertension with accelerated target organ injury, reduced kidney function, and episodic circulatory congestion in patients with renovascular disease predict reduced patient survival. Recent studies indicate that activation of pressor mechanisms depends upon hemodynamic gradients that are often overrated by visual estimates. Although activation of the renin-angiotensin system initiates renovascular hypertension, additional mechanisms perpetuate vascular remodeling and kidney injury that may not depend upon large vessel occlusion. Major advances in medical therapy have led to initiation of at least 4 major prospective trials comparing optimal medical therapy with or without stenting. Up to now, outcome data fail to support broad application of renal revascularization, including results from a recent large, prospective trial from the United Kingdom, despite small groups of patients that experience major clinical benefit. The ambiguity of these results partly reflect poor characterization of the severity of vascular lesions and competing risks within the population related to aging and pre-existing disease. Many patients currently undergoing renal artery interventions derive little net benefit and some are exposed to significant complications, including atheroembolic disease. Determining the appropriate role for renal artery interventions will depend on developing better methods for judging the role of large vessel occlusive disease regarding tissue oxygenation, activation of profibrotic pathways, and irreversible injury in the post-stenotic kidney.