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The ASTRAL Trial results revisited—to stent or not to stent in renal artery stenosis?

Macaulay Onuigbo , Regis Frenandes , Vinay Nijhawan
DOI: http://dx.doi.org/10.1093/qjmed/hcp202 357 First published online: 21 January 2010

The angioplasty and stenting for renal artery lesions (ASTRAL) Investigators found substantial risks without evidence of a worthwhile clinical benefit from revascularization in patients with atherosclerotic renovascular disease.1 Despite these findings, the role of percutaneous transluminal renal angioplasty (PTRA)/stenting in renal artery stenosis (RAS) still remains controversial. Indeed, the ASTRAL Investigators acknowledged that the results of a large trial may disguise a worthwhile clinical benefit in smaller subpopulations of patients.1 We continue to prospectively follow an initial cohort of 26 high-risk chronic kidney disease patients with RAS who all exhibited acute kidney injury (AKI).2,3 In contrast, only 12% of ASTRAL patients exhibited AKI.1 PTRA/stenting was performed in eight patients with persistent renal failure.2,3 An 82-month analysis in June 2009 demonstrated that in seven patients following PTRA/stenting, estimated glomerular filtration rate increased from 27.4 ± 12.7 (11–47) to 50.3 ± 21.7 (23–68) (P = 0.018) after 46.9 months. No procedure-related complications reported. Our prospective patient-level data support the paradigm that PTRA/stenting is useful in RAS patients experiencing new onset acute renal failure/AKI. The message, we submit, is that there is not one treatment that fits all. Pathophysiologic processes involving RAS are complex and treatment modalities must be individualized.

Conflict of interest: None declared.