Recent large randomized controlled trials (RCTs) have shown that renal revascularization does not confer added benefit to unselected patients with atherosclerotic renovascular disease (ARVD) treated with multi-targeted medical therapy. Results suggest that contemporary medical vascular protection therapy has contributed to improved clinical outcomes in ARVD. However, patients with †̃high-riskâ€TM clinical features have largely been excluded from RCTs and there is consistent observational evidence that this specific patient subgroup may gain benefit from revascularization. Timely identification of these patients through risk stratification and prediction of outcomes post-revascularization remain important challenges. The main aims of this epidemiological research project were to explore how treatment and clinical end-points in ARVD have evolved over the past three decades, to identify the determinants of long-term end-points in ARVD, to investigate the effect of revascularization in a selected †̃high-riskâ€TM subgroup, to investigate novel biomarker association of key end-points and finally to develop a clinical risk prediction model that can aid risk stratification and patient selection for revascularization. These individual studies were all based on a local database that includes details of demographic and clinical data for patients with ARVD referred to our tertiary renal centre between 1986 and 2014. Primary end-point measures included death, progression to end-stage kidney disease, cardiovascular events and a composite end-point composed of the first of any of the above events. Management of ARVD has been influenced by RCT results, leading to a decline in the number of revascularization procedures performed. Traditional cardiovascular risk factors together with baseline renal function and proteinuria are the most important determinants of adverse events in ARVD thus advocating the use of multi-targeted medical therapy and aggressive risk factor control in all patients with ARVD. Nonetheless ARVD is a heterogenous condition and results of this research project show that revascularization can be of benefit in patients with rapidly deteriorating renal function, bilateral severe ARVD and/or < 1g/day baseline proteinuria. A panel of novel biomarkers may have incremental risk predictive value when used in conjunction with more traditional risk factors, and NT-proBNP levels may aid patient selection for revascularization. A simple clinical risk-prediction score based on easily obtainable variables may be used as a bedside tool to help risk stratification and facilitate patient selection for revascularization, thus encouraging a more patient-specific therapeutic approach.
| Identifer | oai:union.ndltd.org:bl.uk/oai:ethos.bl.uk:740355 |
| Date | January 2018 |
| Creators | Vassallo, Diana |
| Contributors | Kalra, Philip |
| Publisher | University of Manchester |
| Source Sets | Ethos UK |
| Detected Language | English |
| Type | Electronic Thesis or Dissertation |
| Source | https://www.research.manchester.ac.uk/portal/en/theses/atherosclerotic-renovascular-disease-risk-prediction-and-selection-for-revascularization(ff841ec0-ae14-40a1-9865-dc014f977a77).html |
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