Can infrarenal (below the kidney) disease cause a decrease in glomerular filtration rate (GFR)?

Can Infrarenal Disease Cause Decreased GFR?

Yes, infrarenal disease—particularly infrarenal abdominal aortic aneurysm (AAA) repair—can cause a permanent decline in GFR, with approximately 23% of patients experiencing a ≥20% reduction in estimated GFR within the first year after surgery. 1

Mechanisms of GFR Decline in Infrarenal Disease

Direct Surgical Impact

• Open aortic repair (OAR) of infrarenal AAA independently increases risk of permanent renal function decline (HR 1.69) compared to endovascular repair 1
• Aortic cross-clamping during infrarenal surgery causes transient ischemia to the kidneys, though the immediate postoperative GFR may remain unchanged 2
• Division of the left renal vein during infrarenal aortic reconstruction is the only technical factor that significantly affects GFR changes 2

Delayed Renal Dysfunction Pattern

• The decline in GFR after infrarenal aortic surgery follows a characteristic delayed pattern: GFR remains stable immediately postoperatively but decreases by a mean of 9 mL/min at 6 months 2
• Open repair and suprarenal fixation EVAR both cause significant GFR declines over 2 years (5.49 and 6.57 mL/min/1.73 m² respectively), while infrarenal fixation EVAR causes minimal decline (2.24 mL/min/1.73 m²) 3
• This suggests different causal mechanisms: open repair causes ischemic injury, while suprarenal fixation may cause embolic or inflammatory renal damage 3

Independent Risk Factors for Permanent GFR Decline

The following factors independently predict permanent renal function decline (≥20% eGFR reduction or ESRD) after infrarenal AAA repair: 1

• Pre-existing chronic kidney disease (HR 3.14) 1
• Renal artery stenosis ≥70% (HR 4.34) 1
• Open aortic repair (HR 1.69) 1
• Periprocedural acute kidney injury (HR 15.25) 1

Additive Effect of Modifiable Factors

• Open aortic repair and periprocedural AKI have an additive impact on renal function decline 1
• Patients receiving OAR who develop AKI have the highest frequency of permanent GFR decline 1
• This represents a potentially modifiable risk through careful surgical technique selection and AKI prevention strategies 1

Clinical Significance of GFR Decline

Prognostic Implications

• Even a 30% decline in eGFR over 2 years is strongly associated with subsequent ESRD risk (adjusted 10-year ESRD risk of 64% in patients with baseline eGFR of 35 mL/min/1.73 m²) 4
• A 30% eGFR decline occurs more commonly (6.9% of patients) than the traditional doubling of creatinine (0.79% of patients), making it a more sensitive marker of clinically significant progression 4
• Mortality risk also increases with GFR decline, though the association is weaker than for ESRD 4

Important Caveats

Distinguishing Infrarenal from Intrarenal Disease

• The question "infrarinole" likely refers to infrarenal pathology (below the renal arteries), which differs mechanically from intrinsic kidney disease 5
• Infrarenal aortic disease causes GFR decline through ischemic injury, embolization, and inflammatory mechanisms rather than primary glomerular or tubular pathology 1, 3
• This distinction matters because the pathophysiology involves vascular compromise to otherwise normal kidneys rather than intrinsic renal parenchymal disease 6

Acute vs. Chronic Decline

• Acute kidney injury (AKI) is defined as GFR decline occurring within 7 days, while acute kidney disease (AKD) extends from 7 days to 3 months 5
• Infrarenal surgery can cause both immediate AKI (from ischemia during cross-clamping) and delayed chronic decline (from ongoing ischemic or inflammatory injury) 1, 2
• The delayed pattern of GFR decline after infrarenal surgery suggests ongoing injury mechanisms beyond the immediate perioperative period 2, 3