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Predictors of kidney disease progression after renal artery stenting

BMC Nephrology volume 26, Article number: 175 (2025) Cite this article

Abstract

Background

Atherosclerotic renovascular disease (ARVD) is the most common cause of renal artery stenosis (RAS). ARVD is associated with an increased risk of progression of kidney disease and high mortality. In this regard, the aim was to evaluate the effects of the factors on kidney functions in short- and long-term follow-ups.

Method

Patients with RAS treated with renal artery stenting since January 2015 were evaluated retrospectively in a single center. The primary endpoint was a decline in the estimated glomerular filtration rate (eGFR) of ≥ 20 ml/min and/or evolution to end stage kidney disease. Predictors of the primary endpoint were determined using the Cox regression model.

Results

Of the 95 patients included, 57 (56.4%) were male, and the mean age was 68.7 ± 10.4. Median serum creatinine (mg/dl) and eGFR (ml/min/1.73 m2) at presentation were 1.57 (IQR, 1.11–2.12) and 40 (27–58). The median follow-up was 31 months. Indications for renal artery revascularization included high blood pressure (34 patients, 35.8%), kidney failure (29 patients, 30.5%), or a mixture of these (32 patients, 33.7%). RAS was unilateral in 67 (70%) patients. In the multivariate Cox regression analysis, serum creatinine (HR 2.03, 95% CI 1.3–3.2, p = 0.002), peak systolic velocity (HR 1.005 per 10 ms, 95% CI 1.001–1.010, p = 0.007), and acute kidney injury after revascularization (HR 10.18, 95% CI 2.3–45.4, p < 0.001) were independent predictors of progression of chronic kidney disease.

Conclusion

Serum creatinine level, peak systolic velocity of the renal artery before revascularization, and acute kidney injury after angiographic intervention are independent predictors of the progression of chronic kidney disease in patients who underwent renal artery stenting.

Peer Review reports

Introduction

Atherosclerotic renovascular disease (ARVD) is the most common cause of renal artery stenosis (RAS) and it is relatively common in the elderly [1, 2]. ARVD indicates atherosclerotic burden and is independently associated with another atherosclerotic clinic spectrum that includes peripheral artery disease (PAD), coronary artery disease (CAD), and ischemic nephropathy. ARVD is encountered in approximately half of the patients with peripheral artery disease and one-third of the patients with CAD. Also, RAS is accompanied by 14–25% of patients with resistant hypertension and the incidence increases with aging [2, 3]. ARVD is associated with high mortality rates in patients with chronic kidney disease (CKD). If CKD occurs with RAS the death risk increases to 1.5 times higher in pre-dialysis patients and 3.5 times higher in dialysis patients than other primary causes of CKD [4]. Patients with RAS may present with heterogeneous phenotypes such as resistant hypertension, pulmonary congestion, or progressive kidney disease.

Management of ARVD is still controversial. Determination of patients who benefit from angiographic intervention with stenting is challenging [5]. This is especially the case in patients with mild/asymptomatic RAS, mild hypertension advanced CKD or RAS determined incidentally. It is important to balance between risks such as contrast-induced nephropathy or atheroembolism and benefits due to revascularization of the kidney. Even though randomized controlled studies show that angiographic intervention with stenting when added to standard medical treatment did not provide any benefit to patients’ outcomes [6, 7, 8], some observational studies and expert opinions have reported that restoring renal arterial flow in patients with certain clinical circumstances improves long-term kidney function and reduces the risk of cardiovascular events and death [9, 10]. The clinical phenotypes that may be candidates for percutaneous transluminal renal angioplasty (PTRA) are stated in the European Renal Best Practice (ERBP) guideline prepared by European experts in the past year (Supplemental table). On the other hand, it has been declared that there is a need for further clinical research identifying predictors of PTRA benefit [11].

Even though it is operator-dependent, duplex ultrasonography (DUS) is still the primary imaging method used for the assessment of kidney morphology and arterial blood flow and to determine patients’ candidates for revascularization [12, 13, 14]. Patients with RAS degree > 70%, kidney length > 8 cm, resistive index < 0.8, and cortical thickness > 0.5 cm are likely to benefit from revascularization indicated in the recent guidelines [11, 15].

Previous studies focused on factors that determine response to renal revascularization. However, patients with RAS have a high risk of progression of kidney disease and mortality [4] studies focusing on factors that may be associated with the progression of kidney disease are lacking. Based on this, we aimed to evaluate baseline clinical and imaging factors that affect longer term kidney functions after renal artery stenting.

Methods

Study design and patients

From January 2015 to December 2024 the patients who underwent renal arterial stenting for ARVD in our university were included.

Exclusion criteria included

  • Patients who underwent stenting at another institution,

  • Renal stenting during coronary angiography,

  • RAS due to fibromuscular dysplasia,

  • Insufficient data

  • Exposure to nephrotoxic drugs

The study was approved by the hospital ethics committee, and informed consent was obtained from participants in the study. This study was conducted in accordance with the Declaration of Helsinki.

Variables

The patient’s demographics, clinical characteristics, comorbidities, laboratory parameters, and baseline duplex ultrasound features were evaluated. Estimated glomerular filtration rate (eGFR) was calculated according to CKD-EPI creatinine formula [16]. Acute kidney injury (AKI) was defined according to the KDIGO criteria [17]. The primary endpoint was a a decline in the eGFR of ≥ 20 ml/min and/or evolution to end stage kidney disease [6]. Improvement in kidney function was defined as a ≥ 25% improvement in eGFR during follow up after the procedure [7].

Duplex ultrasonography (DUS)

DUS examinations were performed with the 1–6 MHz convex probe of the GE Logiq S7 (GE HealthCare, USA) device. Patients were evaluated in the supine and slightly lateral decubitus position. Renal arteries were examined in detail along their course and both kidneys were examined in longitudinal and transverse planes. DUS was performed to evaluate RAS before and to evaluate renal artery stent patency after the procedure. Peak systolic velocity (PSV) > 200 cm/sec, renal-aortic ratio (RAR) > 3.5, or renal parenchymal resistance (RI) < 0.55 were evaluated in favor of RAS [11]. In the follow-up of patients with stent placement, PSV > 300 cm/sec within the stent and the presence of post-stenotic turbulence were evaluated as restenosis [11].

Renal angiography

All procedures were done in a dedicated interventional rediology süite using the carbon dioxide (CO2)- Angioset (OptiMed, Ettlingen, Germany). Angiography were performed on Philips Azurion 7 B20/15 and Philips Allura FD 20/10 (Philips, HealthCare, Netherlands). Iohexol (Biomexol, Mefar Istanbul) was used as intravenous contrast agent. Express Vascular SD (Boston Scientific Co, Marlborough, MA, USA) brand balloon expandable stents of 6 mm and 7 mm sizes were used depending on the renal artery diameter. After the procedure, dual antiplatelet therapy was started. Acetylsalicylic acid 100 mg/day and clopidogrel 75 mg/day was started together until one year then asprin was continued.

Statistical analysis

Normality of the data was evaluated using the Kolmogorov-Smirnov test. Categorical variables were presented as counts and percentages. Quantitative variables were given as means with the standard deviation for normal distributions, and median with the interquartile range (25-75%) for non-normal distributions. Predictors of AKI were determined using logistic regression analysis. Results were shown as odds ratios and confidence intervals. Predictors of the primary endpoint were determined by Cox regression analysis. Factors that had a p-value of < 0.1 for the association with the primary endpoint in univariate analysis were included in the multivariable Cox regression model. Results were shown as hazard ratios with confidence intervals. Statistical tests were done using the Statistical Package for Social Sciences (SPSS) version 21.0. A p value of < 0.05 was considered statistically significant.

Results

Of the 95 patients included, 57 (56.4%) were male, and the mean age was 68.7 ± 10.4. Median serum creatinine (mg/dl) and estimated GFR (ml/min/1.73 m2) at presentation were 1.57 (IQR, 1.11–2.12) and 40 (27–58). Indications for renal artery revascularization included high blood pressure (34 patients, 35.8%), kidney failure (29 patients, 30.5%), or a mixture of these (32 patients, 33.7%). RAS was unilateral in 67 (70%) patients. The percentage of stenosis was ≥ 70% in 87 (91.5%) of patients, and 50–70% in the remaining.

Twenty-four (25.3%) patients had progression of CKD. Patients were classified as progressors versus non-progressors. Age and gender distribution were comparable between patients who had progression of CKD versus those who did not (Table 1). In terms of comorbidities, diabetes mellitus was more common in the progression group (15/24 vs. 25/71, p = 0.019). The Systolic (mean 176 vs. 160 mm Hg) and diastolic blood pressure levels (mean 93 vs. 86) of patients who progressed were significantly higher (p < 0.05). The baseline mean serum creatinine was higher among progressors (mean 2.22 vs. 1.58, p = 0.024).

Table 1 Clinical characteristics of the patients are shown in three groups; all, patients with kidney function worsened or not at the end of the follow-up
Full size table

The method for renal artery visualization was intravenous contrast agent in 64 (67.4%), and CO2 angiography in 31 (32.6%). Within the first week of revascularization, seven (6.9%) of patients had acute kidney injury (AKI), and improvement in GFR was observed in 24 (23.8%) of the patients. Improvement in blood pressure was recorded in 63 (66.3%) patients. The median number of antihypertensive drugs before and after the procedure were 3 [2, 3, 4] and 2 (2–3), respectively. Mean systolic and diastolic blood pressure levels before and after the procedure were 164 ± 32/88 ± 19, and 133 ± 20/77 ± 14 mm Hg, respectively. Median serum creatinine within the next week after the procedure was 1.33 (1.03–1.91) mg/dl.

Follow up

During the median follow-up of 31 (6-104) months, 24 patients (25.3%) met the primary outcome of a death-censored decline in GFR for ≥ 20% and or evolution to ESKD, while 10 (9.9%) of the patients remained dialysis-dependent. Restenosis occurred in 8 (7.9%) of the patients. Restenosis was more common in those who developed CKD progression (5/24 vs. 2/71, p = 0.003). At the last visit, the median SCr and eGFR were 1.5 (1.18–2.20), and 38 (25–55), respectively (Table 2). Twenty-nine (29.4%) of the patients had died. Mortality was more common in patients who suffered from progression of CKD (11/24 vs. 17/71, p = 0.051).

Table 2 Follow-up variables of patients whose kidney function worsens or not within the next week following the procedure
Full size table

Predictors of progression

Serum creatinine level before revascularization, PSV, and AKI after revascularization had a p-value of < 0.1 in unadjusted analysis for the association with the progression of CKD (Table 3). In the multivariate Cox regression analysis, serum creatinine (HR 2.03, 95% CI 1.3–3.2, p = 0.002), PSV (HR 1.005 per 10 milliseconds, 95% CI 1.001–1.010, p = 0.007) and AKI after revascularization (HR 10.18, 95% CI 2.3–45.4, p < 0.001) were independent predictors of progression of CKD. For AKI development, the only predictor appeared to be serum creatinine (Table 4). In the logistic regression analysis adjusted for age and sex, the association between serum creatinine and AKI development remained significant (OR 2.24, 95% CI 1.15–4.34, p = 0.017). ROC analysis showed an area under the curve of 0.54 for PSV which is compatible with low sensitivity and specificity of PSV for predicting progression of kidney disease.

Table 3 Predictors of progression of chronic kidney disease in patients who underwent renal artery revascularization
Full size table
Table 4 Predictors of acute kidney injury
Full size table

Acute kidney injury

Of the 7 patients who suffered from AKI, three developed stage 1, two had stage 2, and two had stage 3 AKI. Only one patient with stage 1 AKI recovered kidney function during the follow up. All patients with stage 2–3 AKI experienced progression of CKD, while none of the patients with stage 1 AKI had progression. Stage 1 AKI was not associated with a higher HR for progression compared to patients who did not experience AKI. Stage 2–3 AKI, however, was associated with a higher risk of progression than those who did not have AKI (HR 27.9, 95% CI 6.1-128.6, p < 0.001). Follow up GFR data of patients with AKI are shown in Fig. 1.

Fig. 1
figure 1

Estimated glomerular filtration rate slopes of patients who suffered from acute kidney injury after the renal revascularization

Full size image

Discussion

In this study, our findings indicate that PSV of the renal artery, serum creatinine level prior to revascularization and AKI after angiographic intervention are independent predictors of the progression of kidney disease in patients who underwent renal artery revascularization with stenting. While high PSV has been regarded as a sign for more severe stenosis, and thus associated with a higher likelihood of benefit from revascularization [18], our interesting finding that a higher PSV was associated with the progression of CKD can be explained by possible chronicity of RAS in our patients. Ischemic nephrosclerosis develops after a reduction in blood flow induced by the stenosis. When there is high-grade occlusion, kidney perfusion deteriorates. Long-standing ischemic injury is characterized by inflammation and fibrosis which leads to kidney atrophy, and ultimately organ failure [19, 20]. The turbulent flow represents a chaotic blood flow caused by a narrowing segment of the renal arterial lumen and its counterpart in DUS as PSV of the renal arterial flow that is one of the best parameters used to identify hemodynamically significant RAS [21, 22]. While PSV reveals significant stenosis, its effect on long-term kidney functions has not been demonstrated yet. It’s worth noting that we could not demonstrate a good sensitivity and specificity of a particular cut off level of PSV.

Another important finding of our study is that AKI increased the risk of progression of CKD ten times, however, improvement of kidney function after the procedure did not appear to be significantly associated with improved longer term kidney survival. A higher serum creatinine was the sole independent predictor of AKI. The small number of patients who developed AKI (n = 7) after the procedure makes it difficult to comment on the effect of the procedural method (contrast agent or CO2) on the development of AKI. AKI developed in 9.6% of patients who underwent CO2 angiography and in 6.2% of patients who underwent contrast-agent angiography. As expected, patients with severe AKI (stage 2–3) had a higher risk of progression. None of the patients who suffered from mild AKI (stage 1) had progression. Progression patterns showed that the steep decline in GFR after revascularization followed a stable pattern in patients with severe AKI. Longer follow up is needed to demonstrate the GFR slope in these cases and compare it to patients without AKI. The syndrome of rapid onset ESKD was described in 2010, and was defined as a sudden, unpredictable and abrupt onset to irreversible ESKD after AKI event in any CKD patient with an otherwise a priori stable eGFR > 30 ml/min/1.73m2 [23]. Patients with older age, advanced vascular disease, severe AKI, and who are exposed to renin-angiotensin inhibitors or nephrotoxic agents are more likely to experience irreversible AKI [24]. Evaluation of predisposing factors that may precipitate development of AKI prior to the procedure is important for preserving long-term kidney functions.

Although there is no statistically significant difference, the relatively advanced stage of kidney disease in the patients who underwent CO2 angiography, hemodynamic alterations that may occur as a result of holding CKD-related drugs during the procedure, and micro embolism from extensive aortic atherosclerosis during the angiographic intervention [25, 26] could be caused to occur AKI more frequently in the patients who underwent CO2 angiography in the early period. Distal embolization could partially negate the benefits of revascularization on kidney function [19]. Strategies to limit the occurrence of atheroembolism, such as the use of distal embolic protection systems, may result in improved kidney functions in the long term [20].

In a retrospective study, it was reported that increased pulse pressure was stated as independent predictor for contrast induced AKI after coronary angiography in diabetic patients [27]. This makes sense since a high blood pressure is associated with damage, and low blood pressure represents a chronic atherosclerotic process and also is associated with ischemic injury. Thus, a high pulse pressure may be expected to be associated with unfavorable outcomes. Indeed, our patients who had progression of kidney disease had a higher pulse pressure than non-progressors (mean 80 vs. 73 mm Hg). However, cox regression analysis did not reveal a significant association between pulse pressure and progression. We think this is due to the heterogeneity of indications for revascularization in our patients. Some of our patients underwent the procedure due to uncontrolled blood pressure, while some had progressive kidney failure. Possible predictive role of a high pulse pressure on predicting response to intervention and progression of kidney disease should be tested in further studies.

Randomized controlled studies did not show a benefit of revascularization over medical therapy on kidney function, blood pressure, cardiovascular events and mortality [6, 7, 8]. After the stunning results, clinicians’ doubts revealed whether should abandon renal arterial stenting besides standard medical treatment in patients with ARVD. However, patient selection bias, great variability in these study’s protocol and imaging techniques, low end-point rates, and high rates of cross-over from medical therapy to intervention could significantly influence the results and lead to the need for re-interpretation of those results. In similar times data from prospective cohort studies first from Ritchie et al., reported that ARVD with high-risk clinical presentations such as flash pulmonary edema or patients with rapidly declining kidney function and refractory hypertension may benefit from restoring blood flow of the kidney with stenting [9]. Another study by Reinhard et al. reported that renal artery stenting restored kidney function and reduced blood pressure, daily dose of antihypertensive medications, and re-hospitalization due to pulmonary congestion [18]. Now some clinicians favor renal artery stenting due to ARVD in this field [10]. The current KDIGO and ERBP guidelines for the management of ARVD recommend that in high-risk clinical situations besides standard medical treatment, there are strong indications for revascularization with stenting of high-grade RAS [11, 15]. Therefore our clinic attitude favors angiographic intervention with medical treatment in patients with RAS due to ARVD.

The average age of our research group was 69 years, and 42% had diabetes mellitus and ischemic heart disease as comorbidities. The mortality rate was found to be 29.4%, and the rate of ESKD and dialysis-dependent patients was around 10%. Based on these data, our patient group represents a high-risk patient population in terms of the development of widespread atherosclerotic disease and its’ consequences. In the study of Ritchie et al. [9], who are in favor of angiographic intervention, the mortality rate was expressed as 55% with a median follow-up of 3.8 years. Mortality rates were stated as 25% and 8% in the ASTRAL and STAR studies, respectively [6, 7]. Accordingly, it can be emphasized that older patient groups and those at higher risk may benefit from stenting.

In an international registry by Milewski et al. of 265 patients with ARVD (≥ 50% stenosis) treated with stenting, they showed that patients who improved or preserved kidney function at follow-up had more severe RAS and more decreased eGFR at baseline [28]. In our study, the percentage of stenosis (> 70%) was 91.5% of patients. And PSV of the study group was a median 300 cm/sn, which indicates high-grade stenosis of the renal arterial lumen. In the ASTRAL study, 41% of patients had stenosis of less than 70%, and in the STAR study, 33% of patients had only mild RAS defined as 50–70% [6, 7]. The research group did not consist of patients with relatively high clinical risk may be the reason why angiographic intervention with stenting in RAS did not benefit the endpoints in these studies.

The strengths of the studies are low procedural complication rate, high technical and procedural success, low restenosis rate and the fact that the angiography indication is evaluated by the same center standardizes the process performed. Retrospective desing limits revealing the cause-and-effect relationship. Moreover, the small sample size limits generalizability and analysis for outcomes in more specific patient groups such as those who underwent revascularization for improving blood pressure only, mild kidney failure or more severe kidney failure. For this reason, we performed analysis by including these factors in the regression modeling.

In conclusion, serum creatinine at presentation, development of AKI after revascularization and PSV before revascularization are independent predictors of progression of kidney disease among patients who underwent renal artery stenting. Angiographic revascularization of the kidney may still be valuable for preventing long-term negative outcomes [29]. Especially, measures to reduce the risk of AKI should be carefully evaluated. Further studies are needed to better delineate factors associated with AKI and progression of CKD.

Data availability

Data can be shared upon request from the corresponding author.

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Authors and Affiliations

  1. Division of Nephrology, Dokuz Eylül University School of Medicine, İzmir, Türkiye

    Mehmet Ası Oktan, Cihan Heybeli, Ilker Atay, Berfu Korucu, Yelda Deligöz Bildaci, Serpil Muge Deger & Caner Cavdar

  2. Division of Interventional Radiology, Dokuz Eylül University School of Medicine, İzmir, Türkiye

    Orkun Sarioglu & Aytaç Gulcu

  3. Department of Internal Medicine, Dokuz Eylül University School of Medicine, İzmir, Türkiye

    Esra Ozdemir

  4. Division of Nephrology, Başkent University, İzmir, Türkiye

    Ali Celik

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Contributions

M.A.O. and C.H. analysis the results, reviewed the literature, and wrote the manuscript. O.S., E.O., I.A. and A.G. collected the data B.K., Y.D and S.M.G designed the study and made critical review. A.C. and C.C part of interpretation and critical review.

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Correspondence to Mehmet Ası Oktan.

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Oktan, M.A., Sarioglu, O., Heybeli, C. et al. Predictors of kidney disease progression after renal artery stenting. BMC Nephrol 26, 175 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12882-025-04097-0

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BMC Nephrology

ISSN: 1471-2369

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