biostudies-literatureUnknown8(2)Green D<h4>Rationale & objective</h4>Trials failed to show that angioplasty and stenting of atherosclerotic renovascular disease (ARVD) conferred benefit when used as first-line therapy. However, some patients might benefit from kidney revascularization depending on their clinical phenotype and severity of renal artery stenosis (RAS). We investigated this hypothesis further.<h4>Study design</h4>Data from the Angioplasty and Stenting for Renal Artery Lesions (ASTRAL) randomized trial and Salford ARVD observational study were included in a single analysis.<h4>Setting & participants</h4>Patients were grouped based on RAS severity (≥70%) and whether unilateral or bilateral, with the bilateral group including RAS in a single functioning kidney. High-risk clinical phenotypes included advanced chronic kidney disease (CKD) (estimated glomerular filtration rate < 30 mL/min/1.73 m²), rapid CKD progression (creatinine increase >100 μmol/l or >20% per year), refractory systolic hypertension (≥150 mm Hg on ≥3 agents), and heart failure (chronic or decompensated).<h4>Exposures</h4>Medical therapy alone versus medial therapy and kidney revascularization.<h4>Outcome</h4>Composite of end stage CKD, cardiovascular events, or all-cause mortality.<h4>Analytical approach</h4>Cox proportional hazard model adjusted for age, self-reported gender, and estimated glomerular filtration rate. Analysis of all patients and selected subgroups.<h4>Results</h4>In total, 1,644 patients (806 ASTRAL and 838 Salford). Median (IQR) age 72 (66-77) years. For bilateral severe RAS (≥70%) the HR for the composite outcome for revascularization compared with medical therapy was 0.70 (0.50-0.99), <i>P</i> = 0.048. The clinical phenotype where benefit appeared to be greatest in the presence of bilateral severe disease was people with rapidly progressive kidney disease with a HR of 0.39 (0.22-0.71]). In the absence of bilateral severe RAS, there was no benefit to revascularization for any clinical phenotype.<h4>Limitations</h4>The analyses included observational data.<h4>Conclusions</h4>The presence of bilateral severe RAS may be the best predictor of benefit for kidney revascularization.Kidney medicine101213https://www.ebi.ac.uk/biostudies/studies/S-EPMC12856476biostudies-literaturePatient Selection for Revascularization of Atherosclerotic Renal Artery Stenosis: Comparing the Importance of Stenosis Severity and Clinical Phenotype.PMC12856476O'Keeffe HGreen DCleland JGFChrysochou CChinnadurai RLake EKalra PAfalsePatient Selection for Revascularization of Atherosclerotic Renal Artery Stenosis: Comparing the Importance of Stenosis Severity and Clinical Phenotype.<h4>Rationale & objective</h4>Trials failed to show that angioplasty and stenting of atherosclerotic renovascular disease (ARVD) conferred benefit when used as first-line therapy. However, some patients might benefit from kidney revascularization depending on their clinical phenotype and severity of renal artery stenosis (RAS). We investigated this hypothesis further.<h4>Study design</h4>Data from the Angioplasty and Stenting for Renal Artery Lesions (ASTRAL) randomized trial and Salford ARVD observational study were included in a single analysis.<h4>Setting & participants</h4>Patients were grouped based on RAS severity (≥70%) and whether unilateral or bilateral, with the bilateral group including RAS in a single functioning kidney. High-risk clinical phenotypes included advanced chronic kidney disease (CKD) (estimated glomerular filtration rate < 30 mL/min/1.73 m²), rapid CKD progression (creatinine increase >100 μmol/l or >20% per year), refractory systolic hypertension (≥150 mm Hg on ≥3 agents), and heart failure (chronic or decompensated).<h4>Exposures</h4>Medical therapy alone versus medial therapy and kidney revascularization.<h4>Outcome</h4>Composite of end stage CKD, cardiovascular events, or all-cause mortality.<h4>Analytical approach</h4>Cox proportional hazard model adjusted for age, self-reported gender, and estimated glomerular filtration rate. Analysis of all patients and selected subgroups.<h4>Results</h4>In total, 1,644 patients (806 ASTRAL and 838 Salford). Median (IQR) age 72 (66-77) years. For bilateral severe RAS (≥70%) the HR for the composite outcome for revascularization compared with medical therapy was 0.70 (0.50-0.99), <i>P</i> = 0.048. The clinical phenotype where benefit appeared to be greatest in the presence of bilateral severe disease was people with rapidly progressive kidney disease with a HR of 0.39 (0.22-0.71]). In the absence of bilateral severe RAS, there was no benefit to revascularization for any clinical phenotype.<h4>Limitations</h4>The analyses included observational data.<h4>Conclusions</h4>The presence of bilateral severe RAS may be the best predictor of benefit for kidney revascularization.2026-01-01T00:00:00Z2026 Feb2026-06-20T03:21:08.895Z2026-06-20T03:09:48.997ZS-EPMC128564764162330110.1016/j.xkme.2025.101213