UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

动脉粥样硬化性肾动脉狭窄引起的慢性肾脏病的临床表现及诊断

Authors
Stephen Textor, MD
Lionel U Mailloux, MD, FACP
Section Editors
George L Bakris, MD
Norman M Kaplan, MD
Deputy Editor
John P Forman, MD, MSc
Translators
汪宇鹏, 主治医师

引言与定义

很多(但并非所有)动脉粥样硬化性肾动脉狭窄患者都具有慢性肾脏病(chronic kidney disease, CKD)，这种慢性肾脏病主要是由狭窄引起的血流量下降引起的。一般而言，动脉狭窄影响整个肾脏时会出现临床上明显的CKD(以血清肌酐水平升高为标志)。因此，动脉粥样硬化性肾动脉狭窄导致的CKD患者通常具有双侧肾动脉高度狭窄或功能性孤立肾狭窄。

然而，在由另一种疾病(例如，糖尿病肾病)引起的CKD患者中，“偶尔”也可发现肾动脉狭窄。难以将肾动脉狭窄导致的CKD与另一种原因导致的CKD相区分。

缺血性肾病将在本专题讨论。确定哪些高血压患者行肾动脉狭窄评估、建立肾动脉狭窄的诊断及单侧或双侧动脉粥样硬化性肾动脉狭窄患者的治疗见其他专题。 (参见“哪些患者应评估肾血管性或其他原因的继发性高血压？”和“诊断肾血管性高血压”和“单侧动脉粥样硬化性肾动脉狭窄的治疗”和“动脉粥样硬化性双侧肾动脉狭窄或孤立有功能肾肾动脉狭窄的治疗”)

此外，纤维肌性发育不良的诊断和治疗将在其他专题讨论。 (参见“纤维肌性发育不良的临床表现和诊断”和“肾动脉纤维肌性发育不良的治疗”)

定义与命名

由动脉粥样硬化性肾动脉狭窄导致的CKD通常被称为缺血性肾病[1-3]。广义地讲，“缺血性肾病”是指任何原因所致肾血流量下降导致的肾小球滤过率(glomerular filtration rate, GFR)下降。一般而言，缺血性肾病包括缺血性急性肾小管坏死，由血管炎、凝血或溶血性疾病(如血栓性微血管病或镰状细胞病)或免疫沉积物(与肾小球肾炎一样)导致的肾内动脉或毛细血管阻塞。

       

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: 2017-06 . | This topic last updated: 2016-03-14.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Textor SC, Misra S, Oderich GS. Percutaneous revascularization for ischemic nephropathy: the past, present, and future. Kidney Int 2013; 83:28.
  2. Adamczak M, Wiecek A. Ischemic nephropathy - pathogenesis and treatment. Nefrologia 2012; 32:432.
  3. Chonchol M, Linas S. Diagnosis and management of ischemic nephropathy. Clin J Am Soc Nephrol 2006; 1:172.
  4. Textor SC, Wilcox CS. Ischemic nephropathy/azotemic renovascular disease. Semin Nephrol 2000; 20:489.
  5. Gloviczki ML, Glockner JF, Lerman LO, et al. Preserved oxygenation despite reduced blood flow in poststenotic kidneys in human atherosclerotic renal artery stenosis. Hypertension 2010; 55:961.
  6. Textor SC, Novick AC, Tarazi RC, et al. Critical perfusion pressure for renal function in patients with bilateral atherosclerotic renal vascular disease. Ann Intern Med 1985; 102:308.
  7. Imanishi M, Akabane S, Takamiya M, et al. Critical degree of renal arterial stenosis that causes hypertension in dogs. Angiology 1992; 43:833.
  8. Gloviczki ML, Glockner JF, Crane JA, et al. Blood oxygen level-dependent magnetic resonance imaging identifies cortical hypoxia in severe renovascular disease. Hypertension 2011; 58:1066.
  9. Chade AR, Rodriguez-Porcel M, Grande JP, et al. Distinct renal injury in early atherosclerosis and renovascular disease. Circulation 2002; 106:1165.
  10. Keddis MT, Garovic VD, Bailey KR, et al. Ischaemic nephropathy secondary to atherosclerotic renal artery stenosis: clinical and histopathological correlates. Nephrol Dial Transplant 2010; 25:3615.
  11. Greco BA, Breyer JA. Atherosclerotic ischemic renal disease. Am J Kidney Dis 1997; 29:167.
  12. Rimmer JM, Gennari FJ. Atherosclerotic renovascular disease and progressive renal failure. Ann Intern Med 1993; 118:712.
  13. Safian RD, Textor SC. Renal-artery stenosis. N Engl J Med 2001; 344:431.
  14. Fatica RA, Port FK, Young EW. Incidence trends and mortality in end-stage renal disease attributed to renovascular disease in the United States. Am J Kidney Dis 2001; 37:1184.
  15. Valderrábano F, Berthoux FC, Jones EH, Mehls O. Report on management of renal failure in Europe, XXV, 1994 end stage renal disease and dialysis report. The EDTA-ERA Registry. European Dialysis and Transplant Association-European Renal Association. Nephrol Dial Transplant 1996; 11 Suppl 1:2.
  16. Korsakas S, Mohaupt MG, Dinkel HP, et al. Delay of dialysis in end-stage renal failure: prospective study on percutaneous renal artery interventions. Kidney Int 2004; 65:251.
  17. Textor SC, Wilcox CS. Renal artery stenosis: a common, treatable cause of renal failure? Annu Rev Med 2001; 52:421.
  18. Scoble JE, Hamilton G. Atherosclerotic renovascular disease. BMJ 1990; 300:1670.
  19. Appel RG, Bleyer AJ, Reavis S, Hansen KJ. Renovascular disease in older patients beginning renal replacement therapy. Kidney Int 1995; 48:171.
  20. Mailloux LU, Napolitano B, Bellucci AG, et al. Renal vascular disease causing end-stage renal disease, incidence, clinical correlates, and outcomes: a 20-year clinical experience. Am J Kidney Dis 1994; 24:622.
  21. van Ampting JM, Penne EL, Beek FJ, et al. Prevalence of atherosclerotic renal artery stenosis in patients starting dialysis. Nephrol Dial Transplant 2003; 18:1147.
  22. Leertouwer TC, Pattynama PM, van den Berg-Huysmans A. Incidental renal artery stenosis in peripheral vascular disease: a case for treatment? Kidney Int 2001; 59:1480.
  23. Baboolal K, Evans C, Moore RH. Incidence of end-stage renal disease in medically treated patients with severe bilateral atherosclerotic renovascular disease. Am J Kidney Dis 1998; 31:971.
  24. ASTRAL Investigators, Wheatley K, Ives N, et al. Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med 2009; 361:1953.
  25. Bax L, Woittiez AJ, Kouwenberg HJ, et al. Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function: a randomized trial. Ann Intern Med 2009; 150:840.
  26. Oskin TC, Hansen KJ, Deitch JS, et al. Chronic renal artery occlusion: nephrectomy versus revascularization. J Vasc Surg 1999; 29:140.
  27. Sivamurthy N, Surowiec SM, Culakova E, et al. Divergent outcomes after percutaneous therapy for symptomatic renal artery stenosis. J Vasc Surg 2004; 39:565.
  28. Hadj-Abdelkader M, Alphonse JC, Ravel A, et al. [Proposal of a clinical prediction score for atheromatous renal artery stenosis]. Arch Mal Coeur Vaiss 2003; 96:784.
  29. Madder RD, Hickman L, Crimmins GM, et al. Validity of estimated glomerular filtration rates for assessment of baseline and serial renal function in patients with atherosclerotic renal artery stenosis: implications for clinical trials of renal revascularization. Circ Cardiovasc Interv 2011; 4:219.
  30. Rognant N, Rouvière O, Janier M, et al. Hemodynamic responses to acute and gradual renal artery stenosis in pigs. Am J Hypertens 2010; 23:1216.
  31. MAY AG, DE WEESE JA, ROB CG. Hemodynamic effects of arterial stenosis. Surgery 1963; 53:513.
  32. Drieghe B, Madaric J, Sarno G, et al. Assessment of renal artery stenosis: side-by-side comparison of angiography and duplex ultrasound with pressure gradient measurements. Eur Heart J 2008; 29:517.
  33. De Bruyne B, Manoharan G, Pijls NH, et al. Assessment of renal artery stenosis severity by pressure gradient measurements. J Am Coll Cardiol 2006; 48:1851.
  34. Radermacher J, Ellis S, Haller H. Renal resistance index and progression of renal disease. Hypertension 2002; 39:699.
  35. Herrmann SM, Textor SC. Diagnostic criteria for renovascular disease: where are we now? Nephrol Dial Transplant 2012; 27:2657.
  36. Muray S, Martín M, Amoedo ML, et al. Rapid decline in renal function reflects reversibility and predicts the outcome after angioplasty in renal artery stenosis. Am J Kidney Dis 2002; 39:60.
  37. Novick AC. Patient selection for intervention to preserve renal function in ischemic renal disease. In: Renal Vascular Disease, Novick AC, Scoble J, Hamilton G. (Eds), W.B. Saunders Co, LTD, London 1996. p.323.
  38. Krishnamurthi V, Novick AC, Myles JL. Atheroembolic renal disease: effect on morbidity and survival after revascularization for atherosclerotic renal artery stenosis. J Urol 1999; 161:1093.
  39. Cheung CM, Shurrab AE, Buckley DL, et al. MR-derived renal morphology and renal function in patients with atherosclerotic renovascular disease. Kidney Int 2006; 69:715.
  40. Safian RD, Madder RD. Refining the approach to renal artery revascularization. JACC Cardiovasc Interv 2009; 2:161.