Does Renal Denervation a Reasonable Treatment Option in Hemodialysis-Dependent Patient with Resistant Hypertension? A Narrative Review

Abstract

Purpose of Review This narrative review aims to assess the pathophysiology, diagnosis, and treatment of resistant hypertension (RH) in end-stage kidney disease (ESKD) patients on dialysis, with a specific focus on the effect of renal denervation (RDN) on short-term and long-term blood pressure (BP) control. Additionally, we share our experience with the use of RDN in an amyloidotic patient undergoing hemodialysis with RH. Recent Findings High BP, an important modifiable cardiovascular risk factor, is often observed in patients in ESKD, despite the administration of multiple antihypertensive medications. However, in clinical practice, it remains challenging to identify RH patients on dialysis treatment because of the absence of specific definition for RH in this context. Moreover, the use of invasive approaches, such as RDN, to treat RH is limited by the exclusion of patients with reduced renal function (eGFR < 45 mL/min/1.73 m3) in the clinical trials. Nevertheless, recent studies have reported encouraging results regarding the effectiveness of RDN in stage 3 and 4 chronic kidney disease (CKD) and ESKD patients on dialysis, with reductions in BP of nearly up to 10 mmhg. Summary Although multiple underlying pathophysiological mechanisms contribute to RH, the overactivation of the sympathetic nervous system in ESKD patients on dialysis plays a crucial role. The diagnosis of RH requires both confirmation of adherence to antihypertensive therapy and the presence of uncontrolled BP values by ambulatory BP monitoring or home BP monitoring. Treatment involves a combination of nonpharmacological approaches (such as dry weight reduction, sodium restriction, dialysate sodium concentration reduction, and exercise) and pharmacological treatments. A promising approach for managing of RH is based on catheter-based RDN, through radiofrequency, ultrasound, or alcohol infusion, directly targeting on sympathetic overactivity.

Hypertonietherapie bei Nierenerkrankungen

“…In diversen kleineren Studien konnte man auch in Dialysepatienten eine Blutdrucksenkung um ca. 25 mmHg systolisch beobachten [38]. Diese Ergebnisse sind im Einklang mit Berichten, in denen eine beidseitige Nephrektomie bei 9 von 10 Dialysepatienten die therapieresistente Hypertonie beseitigen konnte [37].…”

Renal Denervation in End-Stage Renal Disease: Current Evidence and Perspectives

“…Furthermore, sympathetic activity increases with CKD progression [ 12 ] and afferent renal nerves, in response to intra-renal injury, may play an excitatory influence on central sympathetic neural outflow [ 13 ]. Finally, renal sympathetic efferent and afferent nerves play a relevant influence in the development, maintenance and progression of elevated BP values commonly detected in patients with ESRD, often leading to resistant hypertension [ 10 , 14 ].…”