st nose d art re r nale histoire naturelle
play

Stnose dartre rnale: Histoire naturelle Physiopathologie et Diagnostic JM Krzesinski Service de Nphrologie CHU Lige ( ) remains the same ( and ) remains the same or decreases EVOLUTION OF

0 downloads 3 Views 2,21 MB Size Report
  1. Sténose d’artère rénale: Histoire naturelle Physiopathologie et Diagnostic JM Krzesinski Service de Néphrologie CHU Liège ( ) remains the same ( and ↓ ) remains the same or decreases EVOLUTION OF RENOVASCULAR HYPERTENSION Etiologies de la SAR Schematic drawing showing theoretical phases of experimental (and clinical) Goldblatt renovascular hypertension. 1

  2. 85-90 10 10 à 15% familial Slovut, D. P. et al. N Engl J Med 2004;350:1862-1871 Parenchymal perfusion and stenosis grade Imaging of Fibroplasia FMD Atheroma Tissue perfusion is ml/min per ml tissue related to stenosis grade in FMD, not in atherosclerotic RAS Lerman et al., Kidney Int 1996;49:846 Slovut, D. P. et al. N Engl J Med 2004;350:1862-1871 Facts about atherosclerotic RAS • Atherosclerotic RAS (ARAS) is a progressive disease. • It affects patients with atherosclerosis elsewhere, and Histoire naturelle d’une SAR long-term outcome is driven by extrarenal disease. athéroscléreuse • Many patients with ARAS need angiotensin- converting enzyme inhibition (ACEI). 2

  3. Safian and Textor, N Engl J Med , 2001, 344 , 430-442. Safian and Textor, N Engl J Med , 2001, 344 , 430-442. Pronostic Safian and Textor, N Engl J Med , 2001, 344 , 430-442. Effect of coexistent RAS on survival among patients having coronary angiography Mortality and renal events in ARAS McLaughlin et al BMJ 2000; 320: 1124 RR for mortality compared Causes of death (7.1-year FU) to the normal population MI 50 % CHF 14 % 3.6 3.3 Stroke 7 % Aneurysm 5 % 2.1 Renal failure 5 % Non-renal non-CV 19 % angina RAS colonic cancer Johansson et al., J Hypertens 1999;17:1743 (n=164) 3

  4. Prévalence des sténoses de l’artère rénale Prévalence pour la population générale : autopsie Prévalence de 5.194 patients (Sawicki et al., J.Int.Med. , 1991) ⇒ 4,3% âge moyen 69 ans Prévalence accrue dans les populations à risque : ⇒ Hypertendus ⇒ Diabétiques Prévalence dépendante de l ’âge Prevalence of RAS by presentation, % Subjects >65 1 7 Coronary heart disease 2 Progression de la SAR 9 History of MI 3 12 Peripheral artery disease 4 23 Flash pulmonary edema 5 34 2 Hansen et al., J Vasc Surg 2002;36:443 2 Conlon et al., Kidney Int 2001;60:1490 3 Uzu et al., Am J Kidney Dis 1997;29:733 4 Swartbol et al., Int Angiol 1992;11:195 5 MacDowall et al., Lancet 1998;352:13 Renovascular disease progression in RAS 49 % with progression n=170, 33-mo follow-up % with atrophy Progression: detectable increase in stenosis 28 grade 21 Atrophy: reduction in 18 12 renal length by > 1 cm * 6 Occlusion * incidence: 3% Normal at <60% ≥ 60% baseline stenosis stenosis Caps Caps et al., Circulation 1998;98:2866 and Kidney Int 1998;53:735 Textor J HTA 2005; 23, suppl 3. 4

  5. Caps Covit A., J Hypertens , 2005; 23 (suppl 3): S15-S22. Jaff M., J Hypertens , 2005; 23 (suppl 3): S1-S3. Gray B., J Hypertens , 2005; 23 (suppl 3): S23-S29. SAR > 70% SAR > 70% ↑ RAA RAA ↑ A II A II Activation plaquettes Activation plaquettes Vasocontriction Vasocontriction ↑ PAI PAI-1 ↑ Endothéline Endoth line Stress oxydatif Stress oxydatif Clinique d’une SAR ↑ Expression Expression ↑ Expression Expression inflammation inflammation ↑ NADPH NADPH remodeling remodeling HTA HTA oxydase oxydase Isch Ischémie mie tissulaire tissulaire MCP -1 MCP PDGF PDGF VCAM -1 VCAM IGF IGF -1 TNF α TNF TGF-ß TGF IL -6 IL 0 2 - Glycoprotéines matricielles Glycoprot ines matricielles PG PG Métalloprot talloprotéinases inases Inflammation Inflammation Fibrose Fibrose Atrophie r Atrophie rénale nale Prévention : angioplastie, antioxydant 5

  6. Interrelation among Renal-Artery Stenosis, Hypertension, and Chronic Renal Failure. Prevalence of HTN in patients with RAS, % CHF + atherosclerotic RAS 1 35 ∼ Elderlies + atherosclerotic RAS 2 53 ∼ CHD + atherosclerotic RAS 3 76 ∼ PAD + atherosclerotic RAS 4 84 > Fibromuscular dysplasia >90 > 1 MacDowall et al., Lancet 1998;352:13 2 Hansen et al., J Vasc Surg 2002;36:443 3 Conlon et al., Kidney Int 2001;60:1490 4 Swartbol et al., Int Angiol 1992;11:195 Safian, R. D. et al. N Engl J Med 2001;344:431-442 Comment explorer? Tests fonctionnels Tests anatomiques Safian and Textor, N Engl J Med , 2004, 344 , 431-442. A 22-year-old woman had had hypertension for one year, a vascular bruit on the left-hand side of the upper abdomen. Renal scanning with [99mTc]pentetic acid (DTPA) (Panel A). The patient was Angioscintigraphie rénale MAG3 then given 25 mg of captopril orally, (Panel B). The scintigraphic images also suggested the presence of stenosis of the left renal artery (confirmed by arteriography). +/- captopril AVANTAGES: • - non invasif • - image fonctionnelle • - DFM DESAVANTAGES: pertes de sensibilité si • - IRénale • - lésions bilatérales • - prise d’inhibiteurs RAA Goto, A. et al. N Engl J Med 2001;344:430 6

  7. ECHO-DOPPLER couleur Angio-IRM + gadolinium AVANTAGES AVANTAGES • - disponibilité, coût • - Vue anatomique 3-D • - non toxique, suivi • - IRénale (+/-) • - réponse tensionnelle (?) • - non opérateur-dépendant DESAVANTAGES DESAVANTAGES • - opérateur-dépendant • - disponibilité • - météorisme et adiposité • - claustrophobie • - peut ne pas voir les artères • - matériel métallique, suivi stent accessoires • -Dysplasie FM Angio-scanner ARTERIOGRAPHIE AVANTAGES AVANTAGES • - anatomie 3-D • - Gold standard • - disponibilité • - traitement dans la foulée DESAVANTAGES DESAVANTAGES • - produit de contraste • - invasif • - irradiation • - produit de contraste • - DFM • - hospitalisation Imaging renal arteries in patients at risk, 2001 MR-derived renal morphology and renal function in ARVD Aortography CT-angio Cheung et al KI 2006; 69, 715 indicated? • 3D-MRI on 35 ARVD MR-angio + gado yes no • DTPA Tc ( single- MR-angio kidney GFR) Captopril scintigraphy flush the • Intérêt de coupler ces renal arteries 2 mesures pour juger Captopril test de l’intérêt de Non-invasive l’angioplastie. tests Vasbinder et al., Ann Intern Med 2001;135:401 reference test: ultrasonography 7

  8. Conclusions • La SAR est fréquente, pas toujours symptomatique. Merci pour votre attention. • Le pronostic, dans le contexte de DFM est bon. • Si contexte d’athérosclérose, le pronostic est surtout lié à l’état vasculaire général du patient. • Le moment et le choix de l’exploration dépendent du patient, de l’expertise locale et du matériel. • La découverte fortuite d’une SAR lors d’un examen ne doit pas obligatoirement conduire à une dilatation. Presentation of 104 unrelated patients % females 90 Mean age at diagnosis 44.1 % with bilateral RAS 54 % with multifocal RAS 78 % with extrarenal stenosis 10 Familial presentation 11 Pannier Pannier-Moreau et al., Moreau et al., J Hypertens 1997;15:1797 J Hypertens 1997;15:1797 8

Recommend Documents


sanika joshi 200601017 what is e nose and e tongue
SANIKA JOSHI(200601017 ) What is

Team F TANU JINDAL(200601014) SANIKA JOSHI(200601017 ) What is e-nose and

le pr diab te
Le PR - DIABTE Faut - il le dpister ?

Le PR - DIABTE Faut - il le dpister ? Faut - il le traiter ? Franoise Fry ( ULB

nose mouth and throat
Nose, Mouth, and Throat Randa M.

Nose, Mouth, and Throat Randa M. Albusoul Anatomy Structure of the Nose:

artificial nose technology the wi nose
Artificial Nose Technology: The WI

Artificial Nose Technology: The WI -Nose A Profitability and Market Analysis

informatique et preuve
Informatique et preuve Une br` eve

Informatique et preuve Une br` eve histoire du raisonnement automatis e

une histoire de mots inattendus et de g nomes
Une histoire de mots inattendus et de

Une histoire de mots inattendus et de gnomes Sophie Schbath ALEA 2017,

a complete solution to the nose gear challenge
A Complete Solution to the Nose Gear

A Complete Solution to the Nose Gear Challenge Yannick Moy Senior Software

5
5 L A Y E R adjustable MEMBRANE

N95 SMALL RESPIRATOR light weight & easy to breathe adjustable nose

design network achieve background
Design. Network. Achieve. Background

Design. Network. Achieve. Background History of White Nose Syndrome and

benign neoplasms of the nose
Benign Neoplasms of the Nose Ivan

Department of Otolaryngology Head and Neck Surgery Pursuing Wellness

april 22 2020 6 00 7 00 pm
April 22, 2020 6:00-7:00 pm

April 22, 2020 6:00-7:00 pm Teleconference: (647) 951-8467 / Toll Free: 1

presenter disclosures
Presenter Disclosures Dr. Gordon Moe

Presenter Disclosures Dr. Gordon Moe Presenter Topic: Management of HFrEF: the

eating amp swallowing deficits in individuals with
Eating & Swallowing Deficits in

2013/06/10 Eating & Swallowing Deficits in Individuals with Dementia

public funding of research eu perspective
Public funding of research EU

Public funding of research EU perspective Presented by: Stefanie Prilla

medical management of coronary artery disease focus on
Medical Management of Coronary Artery

Medical Management of Coronary Artery Disease Focus on Residual Risk Duane

extraction of proteins from palmaria palmata r sa j nsd
Extraction of proteins from Palmaria

Extraction of proteins from Palmaria palmata Rsa Jnsdttir Background

forhp policy updates november 8 2017
FORHP Policy Updates November 8, 2017

FORHP Policy Updates November 8, 2017 CY 2018 Quality Payment Program Final

vignette session c patient safety moderator deepa
Vignette Session C: Patient Safety

Vignette Session C: Patient Safety Moderator: Deepa Bhatnagar, MD Unknown

may 9 11 2018 omaha ne 44th annual midwest pharmacy
May 9-11, 2018 Omaha, NE 44th Annual

May 9-11, 2018 Omaha, NE 44th Annual Midwest Pharmacy Residents Conference

gsk investor presentation
GSK Investor Presentation May 2019

GSK Investor Presentation May 2019 Krupali Engineering researcher Nashik,

autonomic and vascular assessments
Autonomic and Vascular Assessments : q

PC8B SYSTEM Wireless V.5 Autonomic and Vascular Assessments : q A new tool

4 24 2018
4/24/2018 Supervised Exercise Therapy

4/24/2018 Supervised Exercise Therapy for Peripheral Artery Disease (PAD)