Hypertension 2016 11 19;68(5):1145-1152. Epub 2016 Sep 19.
From the Departments of Diagnostic Imaging (T.P.M.) and Medicine (L.D.D.), Rhode Island Hospital, Providence; Alpert Medical School of Brown University, Providence, RI (T.P.M., L.D.D.); Department of Medicine, University of Toledo, OH (C.J.C.); Departments of Statistics (K.M.P., R.B.D, J.M.M.), Medicine (D.E.C.), and Biostatistics (Q.G.), Harvard Clinical Research Institute, Boston, MA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (D.E.C.); Department of Mathematics and Statistics, Boston University, MA (R.B.D.); Department of Medicine, University of Michigan, Ann Arbor (K.J.); Department of Radiology, University of Virginia, Charlottesville (A.H.M.); Department of Medicine, University of Texas Health Science Center, San Antonio (W.H.); Department of Medicine, Marshall University, Huntington, WV (J.I.S.); Department of Medicine, Providence Health Care and University of Washington School of Medicine, Spokane (K.R.T.); Department of Medicine, St. Luke's Hospital, Kansas City, MO (D.J.C.); Departments of Pathology (M.S.) and Medicine (A.H.), The University of Minnesota Medical School, Minneapolis; Department of Medicine, Wellmont-Holston Valley Medical Center, Kingsport, TN (D.C.M.); Department of Medicine, Asheville Cardiology Associates, NC (W.B.A.); Department of Medicine, Mayo Clinic, Rochester, MN (S.C.T.); Department of Radiology, Lancaster General Hospital, PA (J.B.); and Department of Medicine, Sunnybrook Research Institute (S.T.), Toronto, Ontario, Canada.
Randomized clinical trials have not shown an additional clinical benefit of renal artery stent placement over optimal medical therapy alone. However, studies of renal artery stent placement have not examined the relationship of albuminuria and treatment group outcomes. The CORAL study (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) is a prospective clinical trial of 947 participants with atherosclerotic renal artery stenosis randomized to optimal medical therapy with or without renal artery stent which showed no treatment differences (3(5.8% and 35.1% event rate at mean 43-month follow-up). In a post hoc analysis, the study population was stratified by the median baseline urine albumin/creatinine ratio (n=826) and analyzed for the 5-year incidence of the primary end point (myocardial infarction, hospitalization for congestive heart failure, stroke, renal replacement therapy, progressive renal insufficiency, or cardiovascular disease- or kidney disease-related death), for each component of the primary end point, and overall survival. When baseline urine albumin/creatinine ratio was ≤ median (22.5 mg/g, n=413), renal artery stenting was associated with significantly better event-free survival from the primary composite end point (73% versus 59% at 5 years; P=0.02), cardiovascular disease-related death (93% versus 85%; P≤ 0.01), progressive renal insufficiency (91% versus 77%; P=0.03), and overall survival (89% versus 76%; P≤0.01), but not when baseline urine albumin/creatinine ratio was greater than median (n=413). These data suggest that low albuminuria may indicate a potentially large subgroup of those with renal artery stenosis that could experience improved event-free and overall-survival after renal artery stent placement plus optimal medical therapy compared with optimal medical therapy alone. Further research is needed to confirm these preliminary observations.
Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00081731.