Renal artery stenosis: Difference between revisions

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Renal artery stenosis is "narrowing or occlusion of the renal artery or arteries. It is due usually to [[atherosclerosis]]; fibromuscular dysplasia; [[thrombosis]]; embolism, or external pressure. The reduced renal perfusion can lead to renovascular hypertension."<ref>{{MeSH}}</ref>
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'''Renal artery stenosis''' (RAS) is "narrowing or occlusion of the renal artery or arteries. It is due usually to [[atherosclerosis]]; fibromuscular dysplasia; [[thrombosis]]; embolism, or external pressure. The reduced renal perfusion can lead to renovascular hypertension."<ref>{{MeSH}}</ref><ref name="pmid19907044">{{cite journal| author=Dworkin LD, Cooper CJ| title=Clinical practice. Renal-artery stenosis. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 20 | pages= 1972-8 | pmid=19907044
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19907044 | doi=10.1056/NEJMcp0809200 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref> Bilateral RAS can lead to [[chronic kidney disease]].


==Prevalence and epidemiology==
2% of patients underoing coronary angiography in one study had bilateral RAS > 50%.<ref name="pmid15799174">{{cite journal |author=Park S, Jung JH, Seo HS, ''et al'' |title=The prevalence and clinical predictors of atherosclerotic renal artery stenosis in patients undergoing coronary angiography |journal=Heart Vessels |volume=19 |issue=6 |pages=275–9 |year=2004 |month=November |pmid=15799174 |doi= |url= |issn=}}</ref> In this study, 11% had at least unilateral RAS. Of these patients one third do not have a history of [[hypertension]]; however, the rate of hypertension among those with bilateral disease was not reported.
2% of patients underoing coronary angiography in one study had bilateral RAS > 50%.<ref name="pmid15799174">{{cite journal |author=Park S, Jung JH, Seo HS, ''et al'' |title=The prevalence and clinical predictors of atherosclerotic renal artery stenosis in patients undergoing coronary angiography |journal=Heart Vessels |volume=19 |issue=6 |pages=275–9 |year=2004 |month=November |pmid=15799174 |doi= |url= |issn=}}</ref> In this study, 11% had at least unilateral RAS. Of these patients one third do not have a history of [[hypertension]]; however, the rate of hypertension among those with bilateral disease was not reported.


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In an autopsy study, 10 of 15 patients with bilateral RAS (defined as reduction in artery diameter by 50%)<!--(defined as stenosis > 50% of luminal diameter)--> were normotensive by history (defined as diastolic pressure < 100 mm Hg).<ref name="pmid14181143">{{cite journal |author=HOLLEY KE, HUNT JC, BROWN AL, KINCAID OW, SHEPS SG |title=Renal Artery Stenosis. A Clinical-Pathologic Study In Normotensive And Hypertensive Patients  |journal=Am. J. Med. |volume=37 |issue= |pages=14–22 |year=1964 |month=July |pmid=14181143 |doi= |url= |issn=}}</ref> Other autopsy studies are Lisa<ref name="lisa">{{cite journal |author=Lisa JR et al|title=Relationship between arterioscherosis of the renal artery and hypertension |journal=Am J Med Sci|volume=205 |issue= |pages=701 |year=1943|month=June }}</ref> who obtained similar results and Blackman<ref name="Blackman">{{cite journal |author=Blackman SS et al|title=Arterioscherosis and partical obstruction of the main renal arteries in association with "essential" hypertension in man|journal=Bull Johns Hopkins Hosp|volume=65 |issue= |pages=353 |year=1939}}</ref> and Richardson<ref name="Richardson">{{cite journal |author=Richardson GO et al|title=Atherosclerosis of the main renal arteries in essential hypertension |journal=The Journal of pathology and bacteriology|volume=55 |issue= |pages=33 |year=1943|month=June }}</ref> who found lower prevalences.
In an autopsy study, 10 of 15 patients with bilateral RAS (defined as reduction in artery diameter by 50%)<!--(defined as stenosis > 50% of luminal diameter)--> were normotensive by history (defined as diastolic pressure < 100 mm Hg).<ref name="pmid14181143">{{cite journal |author=HOLLEY KE, HUNT JC, BROWN AL, KINCAID OW, SHEPS SG |title=Renal Artery Stenosis. A Clinical-Pathologic Study In Normotensive And Hypertensive Patients  |journal=Am. J. Med. |volume=37 |issue= |pages=14–22 |year=1964 |month=July |pmid=14181143 |doi= |url= |issn=}}</ref> Other autopsy studies are Lisa<ref name="lisa">{{cite journal |author=Lisa JR et al|title=Relationship between arterioscherosis of the renal artery and hypertension |journal=Am J Med Sci|volume=205 |issue= |pages=701 |year=1943|month=June }}</ref> who obtained similar results and Blackman<ref name="Blackman">{{cite journal |author=Blackman SS et al|title=Arterioscherosis and partical obstruction of the main renal arteries in association with "essential" hypertension in man|journal=Bull Johns Hopkins Hosp|volume=65 |issue= |pages=353 |year=1939}}</ref> and Richardson<ref name="Richardson">{{cite journal |author=Richardson GO et al|title=Atherosclerosis of the main renal arteries in essential hypertension |journal=The Journal of pathology and bacteriology|volume=55 |issue= |pages=33 |year=1943|month=June }}</ref> who found lower prevalences.
The clinical relevance of these patients is unclear.<ref name="pmid8292176">{{cite journal |author=Spital A |title=Importance of renal artery stenosis in normotensive patients |journal=Ann. Intern. Med. |volume=119 |issue=10 |pages=1054 |year=1993 |month=November |pmid=8292176 |doi= |url=http://www.annals.org/cgi/pmidlookup?view=long&pmid=8292176 |issn=}}</ref>
==Diagnosis==
A [[clinical prediction rule]] ([http://www.annals.org/cgi/content/full/129/9/705/T2 link]) can help diagnose.<ref name="pmid9841602">{{cite journal |author=Krijnen P, van Jaarsveld BC, Steyerberg EW, Man in 't Veld AJ, Schalekamp MA, Habbema JD |title=A clinical prediction rule for renal artery stenosis |journal=Ann. Intern. Med. |volume=129 |issue=9 |pages=705–11 |year=1998 |month=November |pmid=9841602 |doi= |url=http://www.annals.org/cgi/pmidlookup?view=long&pmid=9841602 |issn=}}</ref>
==Treatment==
Various treatment options exist and no single therapy is superior to others according to a [[systematic review]].<ref name="pmid17062633">{{cite journal |author=Balk E, Raman G, Chung M, ''et al'' |title=Effectiveness of management strategies for renal artery stenosis: a systematic review |journal=Ann. Intern. Med. |volume=145 |issue=12 |pages=901–12 |year=2006 |month=December |pmid=17062633 |doi= |url=http://www.annals.org/cgi/content/full/145/12/901 |issn=}}</ref>
A more recent trial suggests that surgery leads to improved patency rates at 4 years (88% versus 68%); however, angioplasty improved renal function and tended to have less mortality after 4 years (18% vs 25%).<ref name="pmid19135837">{{cite journal |author=Balzer KM, Pfeiffer T, Rossbach S, ''et al'' |title=Prospective randomized trial of operative vs interventional treatment for renal artery ostial occlusive disease (RAOOD) |journal=J. Vasc. Surg. |volume=49 |issue=3 |pages=667–74; discussion 674–5 |year=2009 |month=March |pmid=19135837 |doi=10.1016/j.jvs.2008.10.006 |url=http://linkinghub.elsevier.com/retrieve/pii/S0741-5214(08)01675-3 |issn=}}</ref>
===Angioplasty with or without stents===
Stenting may be safer than surgical revascularization.<ref name="pmid19135837"/>
Stenting improves the patency rates after [[angioplasty]]<ref name="pmid9929021">{{cite journal |author=van de Ven PJ, Kaatee R, Beutler JJ, ''et al'' |title=Arterial stenting and balloon angioplasty in ostial atherosclerotic renovascular disease: a randomised trial |journal=Lancet |volume=353 |issue=9149 |pages=282–6 |year=1999 |month=January |pmid=9929021 |doi=10.1016/S0140-6736(98)04432-8 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(98)04432-8 |issn=}}</ref> This trial found no [[statistical significance]] in differences on blood pressure and renal function; however, this study excluded patients with reduced renal function due to their stenoses.
{| class="wikitable"
|+ Studies of angioplasty with stents<ref name="pmid24245566">{{cite journal| author=Cooper CJ, Murphy TP, Cutlip DE, Jamerson K, Henrich W, Reid DM et al.| title=Stenting and medical therapy for atherosclerotic renal-artery stenosis. | journal=N Engl J Med | year= 2014 | volume= 370 | issue= 1 | pages= 13-22 | pmid=24245566 | doi=10.1056/NEJMoa1310753 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24245566  }} </ref><ref name="pmid19907042">{{Cite journal | doi = 10.1056/NEJMoa0905368 | volume = 361 | issue = 20 | pages = 1953-1962
| last = The ASTRAL Investigators | title = Revascularization versus Medical Therapy for Renal-Artery Stenosis | journal = N Engl J Med
| accessdate = 2009-11-12 | date = 2009-11-12 | url = http://content.nejm.org/cgi/content/abstract/361/20/1953 |pmid=19907042
}}</ref><ref name="pmid19414832">{{Cite journal
| pages = 0000605-200906160-00119 | last = Bax | first = Liesbeth | coauthors = Arend-Jan J. Woittiez, Hans J. Kouwenberg, Willem P.T.M. Mali, Erik Buskens, Frederik J.A. Beek, Branko Braam, Frans T.M. Huysmans, Leo J. Schultze Kool, Matthieu J.C.M. Rutten, Cornelius J. Doorenbos, Johannes C.N.M. Aarts, Ton J. Rabelink, Pierre-Francois Plouin, Alain Raynaud, Gert A. van Montfrans, Jim A. Reekers, Anton H. van den Meiracker, Peter M.T. Pattynama, Peter J.G. van de Ven, Dammis Vroegindeweij, Abraham A. Kroon, Michiel W. de Haan, Cornelis T. Postma, Jaap J. Beutler | title = Stent Placement in Patients With Atherosclerotic Renal Artery Stenosis and Impaired Renal Function: A Randomized Trial | journal = Ann Intern Med | accessdate = 2009-05-06 | date = 2009-05-04 | pmid=19414832 | url = http://www.annals.org/cgi/content/abstract/0000605-200906160-00119v1}}</ref><ref name="pmid11015346">{{cite journal |author=Watson PS et al |title=Effect of renal artery stenting on renal function and size in patients with atherosclerotic renovascular diseas= |journal=Circulation |volume= |issue= |pages= |year=2000 |pmid=11015346 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=11015346 |issn=}}</ref><ref name="pmid7747688">{{cite journal |author=Dorros G et al. |title=Follow-up of primary Palmaz-Schatz stent placement for atherosclerotic renal artery stenosis |journal= Am J Cardio |volume= |issue=|pages= |year=1995  |pmid7747688 = |doi= 0.1016/S0002-9149(99)80723-1  |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(99)80723-1 |issn=}}</ref>
! Study!! Study design!! Patients!!Intervention||Duration !!Outcome !! Results
|-
| CORAL<ref name="pmid24245566">{{cite journal| author=Cooper CJ, Murphy TP, Cutlip DE, Jamerson K, Henrich W, Reid DM et al.| title=Stenting and medical therapy for atherosclerotic renal-artery stenosis. | journal=N Engl J Med | year= 2014 | volume= 370 | issue= 1 | pages= 13-22 | pmid=24245566 | doi=10.1056/NEJMoa1310753 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24245566  }} </ref><br/>2014||[[Randomized controlled trial]]||947 patients with ≥ 60% stenosis and SBP > 155 mmHg on at least two antihypertensive agents||Stent and aspririn and [[thienopyridine]]||43 months ||Various cardiovascular and renal outcomes||No [[statistical significance]]
|-
| ASTRAL<ref name="pmid19907042"/><ref name="pmid17377602">{{cite journal |author=Mistry S, Ives N, Harding J, ''et al.'' |title=Angioplasty and STent for Renal Artery Lesions (ASTRAL trial): rationale, methods and results so far |journal=J Hum Hypertens |volume=21 |issue=7 |pages=511–5 |year=2007 |month=July |pmid=17377602 |doi=10.1038/sj.jhh.1002185 |url=http://dx.doi.org/10.1038/sj.jhh.1002185 |issn=}}</ref><br/>2009||[[Randomized controlled trial]]||806 patients 'unlikely that revascularization will become definitely indicated within the next 6 months'||Stent<br/>77% received [[antiplatelet agent]]s||5 years ||Renal events||No [[statistical significance]]
<!--
|-
|CORAL<ref name="pmid16221898">{{cite journal |author=Murphy TP, Cooper CJ, Dworkin LD, ''et al.'' |title=The Cardiovascular Outcomes with Renal Atherosclerotic Lesions (CORAL) study: rationale and methods |journal=J Vasc Interv Radiol |volume=16 |issue=10 |pages=1295–300 |year=2005 |month=October |pmid=16221898 |doi=10.1097/01.RVI.0000176301.69756.28 |url=http://linkinghub.elsevier.com/retrieve/pii/16/10/1295 |issn=}}</ref>||[[Randomized controlled trial]]||1080 patients with ≥ 60% stenosis and SBP > 155 mmHg on at least two antihypertensive agents||Stent and aspririn and [[thienopyridine]]||3 years ||Various||Not published
-->
|-
| Bax<ref name="pmid19414832"/><br/>2009||[[Randomized controlled trial]]|| 140 patients with creatinine clearance < 80 mL/min per 1.73 m<sup>2</sup>||Stent and aspirin||2 years||20% or greater decrease in [[creatinine clearance]]|| Stents: 16%<br/>Controls: 22%<br/>(No [[statistical significance]])
|-
| Dorros<ref name="pmid11015346"/><br/>1995 || Case series||45 patients with [[hypertension]] and/or [[chronic kidney disease]] || Stent and aspirin, [[dipyridamole]], and [[warfarin]]||6 months || &gt; 0.2 mg/dl decrease in serum creatinine||22% of stented patients had a worsening of renal function
|-
| Watson<ref name="pmid7747688"/><br/>2000|| Case series||76 patients with &gt; 70% stenosis bilaterally or of unilateral kidney and creatinine 1.5 to 4.0 mg/dL||Stent and aspririn and 2 weeks of [[thienopyridine]]||20 months||Slope of serum creatinine over time|| 28% of stented patients had a worsening of renal function
|}
===Surgery===
Surgical revascularization may benefit patients with serum creatinine above 2.0 mg/dl.<ref name="pmid12009679">{{cite journal |author=Uzzo RG, Novick AC, Goormastic M, Mascha E, Pohl M |title=Medical versus surgical management of atherosclerotic renal artery stenosis |journal=Transplant. Proc. |volume=34 |issue=2 |pages=723–5 |year=2002 |month=March |pmid=12009679 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0041134502026234 |issn=}}</ref>


==References==
==References==
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<references>
 
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Renal artery stenosis (RAS) is "narrowing or occlusion of the renal artery or arteries. It is due usually to atherosclerosis; fibromuscular dysplasia; thrombosis; embolism, or external pressure. The reduced renal perfusion can lead to renovascular hypertension."[1][2] Bilateral RAS can lead to chronic kidney disease.

Prevalence and epidemiology

2% of patients underoing coronary angiography in one study had bilateral RAS > 50%.[3] In this study, 11% had at least unilateral RAS. Of these patients one third do not have a history of hypertension; however, the rate of hypertension among those with bilateral disease was not reported.

In a second study of patients patients underoing coronary angiography, 4% has bilateral RAS with both lesions > 50% while 1.5% had both lesions > 75%.[4] Among all the patients with either unilateral or bilateral RAS, half had hypertension.

In an autopsy study, 10 of 15 patients with bilateral RAS (defined as reduction in artery diameter by 50%) were normotensive by history (defined as diastolic pressure < 100 mm Hg).[5] Other autopsy studies are Lisa[6] who obtained similar results and Blackman[7] and Richardson[8] who found lower prevalences.

The clinical relevance of these patients is unclear.[9]

Diagnosis

A clinical prediction rule (link) can help diagnose.[10]

Treatment

Various treatment options exist and no single therapy is superior to others according to a systematic review.[11]

A more recent trial suggests that surgery leads to improved patency rates at 4 years (88% versus 68%); however, angioplasty improved renal function and tended to have less mortality after 4 years (18% vs 25%).[12]

Angioplasty with or without stents

Stenting may be safer than surgical revascularization.[12]

Stenting improves the patency rates after angioplasty[13] This trial found no statistical significance in differences on blood pressure and renal function; however, this study excluded patients with reduced renal function due to their stenoses.

Studies of angioplasty with stents[14][15][16][17][18]
Study Study design Patients Intervention Duration Outcome Results
CORAL[14]
2014		 Randomized controlled trial 947 patients with ≥ 60% stenosis and SBP > 155 mmHg on at least two antihypertensive agents Stent and aspririn and thienopyridine 43 months Various cardiovascular and renal outcomes No statistical significance
ASTRAL[15][19]
2009		 Randomized controlled trial 806 patients 'unlikely that revascularization will become definitely indicated within the next 6 months' Stent
77% received antiplatelet agents		 5 years Renal events No statistical significance
Bax[16]
2009		 Randomized controlled trial 140 patients with creatinine clearance < 80 mL/min per 1.73 m2 Stent and aspirin 2 years 20% or greater decrease in creatinine clearance Stents: 16%
Controls: 22%
(No statistical significance)
Dorros[17]
1995		 Case series 45 patients with hypertension and/or chronic kidney disease Stent and aspirin, dipyridamole, and warfarin 6 months > 0.2 mg/dl decrease in serum creatinine 22% of stented patients had a worsening of renal function
Watson[18]
2000		 Case series 76 patients with > 70% stenosis bilaterally or of unilateral kidney and creatinine 1.5 to 4.0 mg/dL Stent and aspririn and 2 weeks of thienopyridine 20 months Slope of serum creatinine over time 28% of stented patients had a worsening of renal function

Surgery

Surgical revascularization may benefit patients with serum creatinine above 2.0 mg/dl.[20]

References

  1. ↑ Anonymous (2024), Renal artery stenosis (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. ↑ Dworkin LD, Cooper CJ (2009). "Clinical practice. Renal-artery stenosis.". N Engl J Med 361 (20): 1972-8. DOI:10.1056/NEJMcp0809200. PMID 19907044. Research Blogging.
  3. ↑ Park S, Jung JH, Seo HS, et al (November 2004). "The prevalence and clinical predictors of atherosclerotic renal artery stenosis in patients undergoing coronary angiography". Heart Vessels 19 (6): 275–9. PMID 15799174. [e]
  4. ↑ Harding MB, Smith LR, Himmelstein SI, et al (May 1992). "Renal artery stenosis: prevalence and associated risk factors in patients undergoing routine cardiac catheterization". J. Am. Soc. Nephrol. 2 (11): 1608–16. PMID 1610982. [e]
  5. ↑ HOLLEY KE, HUNT JC, BROWN AL, KINCAID OW, SHEPS SG (July 1964). "Renal Artery Stenosis. A Clinical-Pathologic Study In Normotensive And Hypertensive Patients". Am. J. Med. 37: 14–22. PMID 14181143. [e]
  6. ↑ Lisa JR et al (June 1943). "Relationship between arterioscherosis of the renal artery and hypertension". Am J Med Sci 205: 701.
  7. ↑ Blackman SS et al (1939). "Arterioscherosis and partical obstruction of the main renal arteries in association with "essential" hypertension in man". Bull Johns Hopkins Hosp 65: 353.
  8. ↑ Richardson GO et al (June 1943). "Atherosclerosis of the main renal arteries in essential hypertension". The Journal of pathology and bacteriology 55: 33.
  9. ↑ Spital A (November 1993). "Importance of renal artery stenosis in normotensive patients". Ann. Intern. Med. 119 (10): 1054. PMID 8292176. [e]
  10. ↑ Krijnen P, van Jaarsveld BC, Steyerberg EW, Man in 't Veld AJ, Schalekamp MA, Habbema JD (November 1998). "A clinical prediction rule for renal artery stenosis". Ann. Intern. Med. 129 (9): 705–11. PMID 9841602. [e]
  11. ↑ Balk E, Raman G, Chung M, et al (December 2006). "Effectiveness of management strategies for renal artery stenosis: a systematic review". Ann. Intern. Med. 145 (12): 901–12. PMID 17062633. [e]
  12. ↑ 12.0 12.1 Balzer KM, Pfeiffer T, Rossbach S, et al (March 2009). "Prospective randomized trial of operative vs interventional treatment for renal artery ostial occlusive disease (RAOOD)". J. Vasc. Surg. 49 (3): 667–74; discussion 674–5. DOI:10.1016/j.jvs.2008.10.006. PMID 19135837. Research Blogging.
  13. ↑ van de Ven PJ, Kaatee R, Beutler JJ, et al (January 1999). "Arterial stenting and balloon angioplasty in ostial atherosclerotic renovascular disease: a randomised trial". Lancet 353 (9149): 282–6. DOI:10.1016/S0140-6736(98)04432-8. PMID 9929021. Research Blogging.
  14. ↑ 14.0 14.1 Cooper CJ, Murphy TP, Cutlip DE, Jamerson K, Henrich W, Reid DM et al. (2014). "Stenting and medical therapy for atherosclerotic renal-artery stenosis.". N Engl J Med 370 (1): 13-22. DOI:10.1056/NEJMoa1310753. PMID 24245566. Research Blogging.
  15. ↑ 15.0 15.1 The ASTRAL Investigators (2009-11-12). "Revascularization versus Medical Therapy for Renal-Artery Stenosis". N Engl J Med 361 (20): 1953-1962. DOI:10.1056/NEJMoa0905368. PMID 19907042. Retrieved on 2009-11-12. Research Blogging.
  16. ↑ 16.0 16.1 Bax, Liesbeth; Arend-Jan J. Woittiez, Hans J. Kouwenberg, Willem P.T.M. Mali, Erik Buskens, Frederik J.A. Beek, Branko Braam, Frans T.M. Huysmans, Leo J. Schultze Kool, Matthieu J.C.M. Rutten, Cornelius J. Doorenbos, Johannes C.N.M. Aarts, Ton J. Rabelink, Pierre-Francois Plouin, Alain Raynaud, Gert A. van Montfrans, Jim A. Reekers, Anton H. van den Meiracker, Peter M.T. Pattynama, Peter J.G. van de Ven, Dammis Vroegindeweij, Abraham A. Kroon, Michiel W. de Haan, Cornelis T. Postma, Jaap J. Beutler (2009-05-04). "Stent Placement in Patients With Atherosclerotic Renal Artery Stenosis and Impaired Renal Function: A Randomized Trial". Ann Intern Med: 0000605-200906160-00119. PMID 19414832. Retrieved on 2009-05-06.
  17. ↑ 17.0 17.1 Watson PS et al (2000). "Effect of renal artery stenting on renal function and size in patients with atherosclerotic renovascular diseas=". Circulation. PMID 11015346. [e]
  18. ↑ 18.0 18.1 Dorros G et al. (1995). "Follow-up of primary Palmaz-Schatz stent placement for atherosclerotic renal artery stenosis". Am J Cardio. DOI:0.1016/S0002-9149(99)80723-1. Research Blogging.
  19. ↑ Mistry S, Ives N, Harding J, et al. (July 2007). "Angioplasty and STent for Renal Artery Lesions (ASTRAL trial): rationale, methods and results so far". J Hum Hypertens 21 (7): 511–5. DOI:10.1038/sj.jhh.1002185. PMID 17377602. Research Blogging.
  20. ↑ Uzzo RG, Novick AC, Goormastic M, Mascha E, Pohl M (March 2002). "Medical versus surgical management of atherosclerotic renal artery stenosis". Transplant. Proc. 34 (2): 723–5. PMID 12009679. [e]

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