Detection of severe bilateral atherosclerotic renovascular disease by ACE-inhibitor induced renal dysfunction.
ASN 30th Annual Meeting, San Antonio
J Am Soc Nephrol (Sep) 8:324A 1997
The risk of worsening renal failure in patients with bilateral renal artery stenosis (RAS) or stenosis of a single renal artery, is well recognized. The authors undertook an innovative approach to use this adverse effect of ACE inhibitors to functionally diagnose the elusive bilateral renovascular disease.
108 patients with suspected severe bilateral RAS were prospectively studied. ACE inhibitors were given for a maximum of 2 wk. and serum creatinine was followed. A rise over 20% of initial creatinine was considered indicative of bilateral RAS. When the blood pressure did not respond to ACE inhibition alone, diuretics were added to the regimen (n=15); a measure that conceivably could increase the sensitivity of the test. Hypotension was avoided by fluid administration (n=2). All 52 patients who had >50% bilateral RAS were correctly identified by the test (100% sensitivity). Of the remaining 56 patients with mild RAS or normal renal arteries, 17 were falsely identified by the test of having severe RAS (specificity 70%). Among those patients who underwent successful revascularization (stent or PTA) 36 had a repeat ACE test and angiography within 6 months post-intervention. Of the 12 patients with severe restenosis, 11 had positive test (92% sensitivity). 23 of the 24 patients without restenosis were correctly identified by a negative ACE inhibitor test (96% specificity).
Comment: The sensitivity and specificity of the ACE inhibitor test in this selected group of patients, in the hands of the authors, is remarkable. Whether similarly encouraging results can be reproduced in different centers, under different circumstances, remains to be seen. It is reassuring that the test correctly changed from positive to negative in all but one successfully dilated patients and remained positive in all but one patients without proper response to the revascularization. Although the authors did not report side effects, the remote possibility of severe or irreversible drop in renal function caused by ACE inhibition in patients with high risk for bilateral RAS should remain a concern. (Laszlo Hopp, Alfred I. duPont Hospital for Children; Wilmington, DE)
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ASN 30th Annual Meeting, San Antonio
H: Special problems : Renovascular hypertension