Badanie CORAL – czy poszerzanie miażdżycowo zmienionych tętnic nerkowych daje wymierne korzyści ?

Marzec 24, 2014  |  Udostępnij  | 

Zdecydowana większość pacjentów z nadciśnieniem tętniczym (prawdopodobnie ok. 90%) cierpi na tzw. nadciśnienie pierwotne – bez uchwytnej przyczyny. U pozostałych możemy jednak wskazać czynnik etiologiczny. Do tej drugiej grupy należą chorzy ze zwężeniem tętnicy nerkowej. Patologia ta prowadzi do zaburzenia ukrwienia nerek, co skutkuje nadmierną stymulacją układu renina-angiotensyna-aldosteron (RAA) i wzrost ciśnienia tętniczego. Jednocześnie przewlekle niedokrwione nerki ulegają uszkodzeniu i z czasem stają się niewydolne, co dodatkowo pogarsza sytuację kliniczną pacjenta. Receptą na tę patologię wydaje się prosta – poszerzenie tętnicy nerkowej z implantacją stentu. Niemniej dotychczasowe badania kliniczne nie udowodniły korzystności takiej procedury  w zapobieganiu nadciśnieniu tętniczemu, powikłaniom sercowo-naczyniowym, czy postępowi niewydolności nerek.

Niedawno ukazały się wyniki kolejnego badania dotyczącego tego problemu. Duże wieloośrodkowe badanie pod akronimem CORAL[1] miało za zadanie porównanie dwóch schematów postępowania: stentowania tętnicy nerkowej w połączeniu z farmakoterapią i samej farmakoterapii, u chorych z ciężkim zwężeniem tętnicy nerkowej na tle miażdżycowym powikłanym nadciśnieniem tętniczym i/lub przewlekłą chorobą nerek. Jako „ciężkie” przyjmowano te zmiany w naczyniach, które zawężały ich światło o co najmniej 60%, ale nie zamykały go całkowicie. Nie brano pod uwagę chorych z inną etiologią zwężeń w tętnicach nerkowych, czy niewydolnością nerek o etiologii innej niż niedokrwienna. Poziom kreatyniny w momencie włączenia do badania nie mógł przekraczać 4 mg/dl. Tak jak w większości randomizowanych badań klinicznych pacjenci zostali losowo podzieleni na dwie grupy – leczoną wyłącznie farmakologicznie oraz leczoną implantacją stentu firmy Plazmaz-Genesis w połączeniu z farmakoterapią. W ciągu pięciu lat trwania rekrutacji do udziału w eksperymencie zakwalifikowano 947 pacjentów, których obserwowano przeciętnie przez 3,5 roku. Do zdarzeń tworzących złożony, pierwszorzędowy punkt końcowy zaliczono: zgon z przyczyn sercowo-naczyniowych lub nerkowych, zawał serca, udar mózgu oraz hospitalizację z powodu niewydolności serca lub nerek. Po przeanalizowaniu wszystkich dostępnych danych nie zaobserwowano istotnej statystycznie różnicy pomiędzy obiema grupami pod względem występowania wyżej opisanego punktu końcowego (35,1vs.35,8%; p>0,5) . Takiej różnicy nie odnotowano także w odniesieniu do którejkolwiek z jego składowych. Wszczepienie stentu w połączeniu z farmakoterapią, w porównaniu do samej farmakoterapii, nie wpłynęło także na lepszą kontrolę ciśnienia tętniczego u osób badanych – średni poziom ciśnienia skurczowego w czasie obserwacji spadł porównywalnie w obu grupach. Podobnie, porównywalnie wzrosła średnia liczba zażywanych leków hipotensyjnych w przeliczeniu na pacjenta (z około 2 do ponad 3 na koniec okresu follow-up). Jednocześnie zabiegi implantacji stentu w tętnicy nerkowej nie były wolne od powikłań. Najczęstszym spośród istotnych zdarzeń niepożądanych było rozwarstwienie naczynia – dotknęło ono 11 chorych.

Podsumowując można stwierdzić, że zabieg poszerzenia zwężonej miażdżycowo tętnicy nerkowej nie poprawia kontroli ciśnienia tętniczego u chorych z dobrze prowadzoną farmakoterapią hipotensyjną. U tych pacjentów implantacja stentu nie poprawia także ogólnego rokowania co do czasu przeżycia, nie zmniejsza liczby zdarzeń sercowo-naczyniowych, a także nie ma wpływu na spowolnienie postępu przewlekłej niewydolności nerek. Warto jednak podkreślić, że uzyskane wyniki mają zastosowanie do osób intensywnie leczonych farmakologicznie, a korzystny wpływ poszerzenia zwężonej tętnicy nerkowej u chorych źle prowadzonych lub nie stosujących się do zaleceń, wciąż pozostaje niejasny.

 

1. Cooper CJ et al., Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med. 2014 Jan 2;370(1):13-22.


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cystoscopy s i sT O Sk o p e cystostomy s i sT O St o m e diabetes insipidus d i a B E t e z i nS I P i d u s diabetes mellitus d i a B E t e z M E L i t u s URINARY SYSTEM TERM PRONUNCIATION MEANING diuresis d i u rR E s i s dysuria d i s U r e a edema e D E m a electrolyte e L E Ktr o l i t enuresis e n u R E s i s erythropoietin e r i thr o P OY e t i n essential hypertension e S E Nsh u l h i p e rT E Nsh u n ltration f i lTR A sh u n glomerular capsule gl o M E R u l a r K A Ps u l glomerulonephritis gl o m e r u l o n e FR I t i s glomerulus plural glomeruli gl o M E R u l u s gl o M E R u l i glycosuria gl i k o s U r e a hematuria h e m a T U r e a hemodialysis h e m o d i A L i s i s hilum H I l u m hydronephrosis h i dr o n e FR O s i s hyperkalemia h i p e rk a L E m e a hyponatremia h i p o n a TR E m e a interstitial nephritis i nt e rST I sh u l n e FR I t i s intravesical i ntr a V E S i k a l ketonuria k e t o n U r e a ketosis k e T O s i s kidney K I Dn e lithotripsy 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  13. Saunders D Jager HR Murray AD Stevens JM.Vaccines are now also available to prevent the disease in animals but people die from rabies globally every year.The left prefrontal cortex is associated with more positive emotional states or the tendency to approach. [url=http://buysildenafil100mg-us.com]viagra generic cialis generic viagra[/url] A yearold Caucasian male comes to the clinic with a day history of chest pain.You are the best My family and friends continue to be my greatest comfort and support.This can be done via fiberoptic bronchoscopy with transbronchial biopsy a limited amount of tissue can be obtained which limits its utility open lung biopsy or videoassisted thoracoscopic lung biopsy.Goldstein and Goldstein et al.Everyone enjoys a little dessert after dinner but when the ice cream or a creamy tart leads to pain most would avoid it. [url=http://buycheaplasixus.com]cheap lasix 40 mg[/url] The condition is most often caused by alcoholism and alcohol abuse of cases in the United States.akgimages Paul Almasy cr Corbis Wavebreak Media Ltd.The societys aims included rigid examination into the causes and conditions which influence the origin propagation mitigation and prevention of epidemic diseases.This can be a sign of a blood clot.LVAD left ventricular assist deviceMalignancy is the most common cause of death. [url=http://erxbid.com]cialis precio lima[/url] RUNX genes in development and cancer regulation of viral gene expression and the discovery of RUNX family genes.Apraxia and aphasiaIt is a disease with high morbidity but low mortality.In particular they thought disease was due to misbehavior or wrongdoing on the part of the sufferer. [url=http://farpot.com]comprar kamagra en valencia[/url] Usually fibrillation does not stop when the current source is removed.Clinical featuresGlimpses of this development can be seen in the early civilizations of West Asias Fertile Crescent or Mesopotamiathe land of the TigrisEuphrates river system now mainly Iraq plus adjoining parts of Turkey Syria and Iran.Other nonphysicians trained in the treatment of mental illness include licensed clinical social workers psychiatric nurses and licensed mental health clinicians LMHCs.The disease is more common in parts of Africa and Asia than in North or South America and Europe.Diabetic retinopathy a. [url=http://kamxl.com]cheap kamagra jelly india 219[/url] Physicians should consider prescribing epinephrine in patients with urticaria until the diagnosis of anaphylaxis is exclude Diagnosis of Acute Urticaria and Angioedema Acute urticaria can be considered as a symptom of many diseases rather than a disease itself.You are the best My family and friends continue to be my greatest comfort and support.

  14. . [url=http://urmyrx.net]kamagra oral jelly no presc[/url] psychiatrypyromania Pyro means re heat.A study of prostatic tissue levels of latamoxef cefoperazone and cefotaxime in Japanese.New York NY McGrawHill chapIndeed by the time Pare attended the Hotel Dieu the reputation of barbersurgeons was growing.VT after an MI usually has a poor prognosis especially if it is sustained.It can be shown from the conditions for equilibrium see Appendix A that for all three types of levers the force F required to balance a load of weight W is given by F W d dDepression was more common in the COPD group. [url=http://shopbestmedrxed.com]generic cialis 200mg[/url] b.Treatment Treatment involves using medicines to kill the cancer cells.MVP is the most common cause of mitral regurgitation in developed countries.for help with unfamiliar or difcult words.confidence interval CI [url=http://24drugs.net]priligy euro[/url] The fact that the organ was a heartthe symbol of lifeposed new medical ethical and social questions about the dividing line between life and death.uncomfortable sensations in the chest associated with arrhythmiasOther conditions such as gastroesophageal reux disease GERD sinusitis and allergic rhinitis can exacerbate asthma.Also reviewed by A. [url=http://buyfinasteridenorx.com]lower price on finasteride camber[/url] c.What is the likely diagnosis and the appropriate management of this patientReview provided by VeriMed Healthcare Network.uncontrollable urge to perform an act repeatedlyThese involve the internal capsule cerebral peduncles thalamus and pons. [url=http://newpharmnorx.com]fastest cialis delivery[/url] Significantly more furosemide is excreted in urine following the IV injection than after the tablet or oral solution.Caused by deficiency or defect of factor VIII coagulant proteinThe first bag that is hung is the primary infusion.

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  16. Examination of the trans mitted light reveals the missing wavelengths which identify the components in the substance.All rights reserved No part of this publication may be reproduced stored in a retrieval system or transmitted in any form or by any means electronic mechanical photocopying recording or otherwise without the prior written permission of the publisher Permissions may be sought directly from Elseviers Science Technology Rights Department in Oxford UK phone fax email permissionselsevier.The Lippincott Manual of Nursing Practice.Kaneshiro MD MHA Clinical Assistant Professor of Pediatrics University of Washington School of Medicine and Luc Jasmin MD PhD Department of Neurosurgery at CedarsSinai Medical Center Los Angeles and Department of Anatomy at UCSF San Francisco CA. [url=http://deplim.com]order synthetic viagra[/url] c.ETB receptor activation is known to possibly induce a NOmediated decrease in penile vascular tone Ari et al.percussion Tapping on a surface to determine the difference in the density of the underlying structure.Adult women account for to of cases.b. [url=http://buykamagrapillsus.com]buy kamagra jelly india[/url] A quadricepshamstring rehabili tation program aimed at stretching and strengthening these muscles helps unload the patella and shift the load to the thigh muscles.PubMed Meuleman E Cuzin B Opsomer RJ Hartmann U Bailey MJ Maytom MC.In Lister returned to Edinburgh as Professor of Clinical Surgery.R m g m x o r R mof the study sample. [url=http://catabs.com]priligy online espana[/url] Sexual activity causes an increase in the cardiopulmonary load.NSAIDs and corticosteroids are contraindicated may hinder myocardial scar formation.If you were to perform a spiritual needs assessment on yourself what would be your strengths What are your areas of vulnerability Can you recall a time in the past when your spiritual needs were not being met What helped or hurtLauterbur inIt usually occurs on sundamaged skin.Medicines and fluids pass through this IV. [url=http://buycheaplasixus.com]canadian pharmacy lasix pills[/url] Other imaging tests can look at how well your heart is able to pump blood and how much the heart muscle is damaged.The Obama Effect How a Salient Role Model Reduces RaceBased Performance Differences.et al.cholangiography Xray imaging after injection of contrast into bile ducts.The problem he raised had a relation with feeling attraction since several years before to people of both sexes which he experienced as something painful and being afraid of loss erection.Blood leaves the body enters the heartlung machine where it is oxygenated and then returns to a blood vessel artery to circulate through the bloodstream.Imaging studies ultrasound CT identify the abscess but it is difficult to distinguish from a pyogenic abscess. [url=http://misude.com]buy priligy[/url] Pharm.

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  23. K. [url=http://audrugs.com]canada generic viagra[/url] Diseases of the Kidney and Urinary Tract.J.phagiaCombining Forms COMBINING FORM MEANING COMBINING FORM MEANING adeno hemo hemato arthro hepato bio iatro carcino leuko cardio logo cephalo nephro cerebro neuro ciso onco crino ophthalmo cysto osteo cyto patho dermo dermato pedo electro psycho encephalo radio entero reno erythro rhino gastro sarco glyco secto gnoso thrombo gyneco uro BASIC WORD STRUCTURE Sufxes SUFFIX MEANING SUFFIX MEANING ac itis al logy algia oma cyte opsy ectomy osis emia pathy genic scope globin scopy gram sis ic ical tomy ion y ist Prexes PREFIX MEANING PREFIX MEANING a an in aut auto peri dia pro endo re epi retro ex exo sub hyper trans hypo Please visit the Evolve website for additional exercises games and images related to this chapter. [url=http://tromal.com]worldwide pharmacy kamagra[/url] It has also been reported that the Kras oncogene is mutated in of large adenomas and CRC the mutated constitutively active form of this pro tein affects signaling pathways controlling cellular differ entiation motility proliferation and apoptosisKeep in mind that cardiogenic pulmonary edema has to be distinguished from ARDSlook for signs of volume overload CHF JVD edema and hepatomegaly.Roberts LR.The condition is most often caused by alcoholism and alcohol abuse of cases in the United States.You are more likely to get this disease if you Scandinavian or Northern European Have a family history of the condition Certain diseases can also raise your risk. [url=http://azithromycinpurchase.com]imitrex buy u.s canada[/url] Free wall rupture A catastrophic usually fatal event that occurs during the first weeks after MI within weeks most commonly to days after MI mortality rate Usually leads to hemopericardium and cardiac tamponade Treatment Hemodynamic stabilization immediate pericardiocentesis and surgical repair b.For example a healthy digestive system was said to give the tongue an appealing red freshness.PREFIXES PREFIX MEANING TERMINOLOGY MEANING anti against antibiotic Antibiotics destroy or inhibit the growth of microorganisms such as bacteria.The pulp lies underneath the dentin.An accident on August brought yearold James Greenlees into Glasgow Royal Infirmary.A. [url=http://etaze.net]cialis precio[/url] e Foroud T.ECG Often suggests right ventricular hypertrophyspecifically right axis devia tion and right atrial abnormality are frequently present.Standard The initial trial dose of intracavernous injection therapy should be administered under healthcare provider supervision.Treatmentthyroid hormone to achieve euthyroid state D.Hematochezia bloody diarrhea [url=http://banzell.com]ajanta pharma limited kamagra[/url] It is best to attempt to identify any predisposing conditions and eliminate them if possible.B from Daffner RH.This often results in diabetic men reporting more severe ED when they present for treatment of this condition.

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