Endovascular Renal Denervation in End-Stage Kidney Disease Patients: Cardiovascular Protection—A Proof-of-Concept Study

Abstract

IntroductionSympathetic neural activation is markedly increased in end-stage kidney disease (ESKD). Catheter-based renal denervation (RDN) reduces sympathetic overactivity and blood pressure in resistant hypertension. We investigated the effect of RDN on sympathetic neural activation and left ventricular mass in patients with ESKD.MethodsNine ESKD (6 hemodialysis and 3 peritoneal dialysis) patients with dialysis vintage of ≥11 months were treated with RDN (EnligHTN system). Data were obtained on a nondialysis day; at baseline, 1, 3, and 12 months post-RDN.ResultsAt baseline sympathetic neural activation measured by muscle sympathetic nervous activity (MSNA) and plasma norepinephrine concentrations were markedly elevated. Left ventricular hypertrophy (LVH) was evident in 8 of the 9 patients. At 12 months post-RDN, blind analysis revealed that MSNAfrequency (–12.2 bursts/min1, 95% CI [–13.6, –10.7]) and LV mass (–27 g/m2, 95% CI [–47, –8]) were reduced. Mean ambulatory BP (systolic: –24 mm Hg, 95% CI [–42, –5] and diastolic: –13 mm Hg, 95% CI [–22, –4]) was also reduced at 12 months. Office BP was reduced as early as 1 month (systolic: –25 mm Hg, 95% CI [–45, –5] and diastolic: –13 mm Hg, 95% CI [–24, –1]). Both ambulatory and office BP had clinically significant reductions in at least 50% of patients out to 12 months.DiscussionCatheter-based RDN significantly reduced MSNA and LV mass as well as systemic BP in this group of patients with ESKD.

Efficacy and safety of renal denervation for hypertension in patients with chronic kidney disease: a meta-analysis

“…Of the 35 studies included in the full-text evaluation, seven were excluded because they were case reports, three were excluded because of the study protocol, two were excluded for insufficient data, two were excluded for duplicate patient data, and 10 did not meet the inclusion criteria. Finally, 11 single-center, non-randomized, uncontrolled studies were included in the meta-analysis (Figure 1) [18][19][20][21][22][23][24][25][26][27][28]. These 11 studies included 238 patients and are summarized in Table 1.…”

“…Three major complications (hematoma, femoral pseudoaneurysm, and bleeding) were reported after RDN [19,21,23,25]. Only one article reported the data of the bleeding complication [21].…”

Sympathetic overactivity in dialysis patients—Underappreciated and clinically consequential

“…Endovascular renal denervation (RDN) reduces MSNA both in a resistant hypertensive population and in ESKD . Unlike the traditional invasive surgical approach, RDN involves a percutaneous, catheter‐based method, whereby typically radiofrequency waves are applied to the endothelial surfaces of both renal arteries.…”

“…A reduction in MSNA indicates why blood pressure, LVH, and systolic and diastolic function improve following successful denervation even when vascular stiffness and calcification have become so advanced. These effects, as well as an understanding of the pathophysiology of sympathetic activation in ESKD, give insight as to why the technique may also be a useful therapeutic avenue in this population .…”

Briefly Noted

“…Endovascular renal denervation in 9 hypertensive dialysis patients was associated with a reduction at 12 months of ambulatory BP (mean, −24/−13 mm Hg) and left ventricular mass (−13%) . BP meds were reduced in 2 patients and increased in 1 patient.…”