Long‐Term Effects of Renal Sympathetic Denervation on Hypertensive Patients With Mild to Moderate Chronic Kidney Disease

Abstract

Thirty patients who underwent percutaneous renal denervation, which was performed by a single operator following the standard technique, were enrolled in this study. Patients with chronic kidney disease (CKD) stage 2 (n=19), 3 (n=6), and 4 (n=5) were included. Data were obtained at baseline and at monthly intervals for the first 6 months. At 7 months, follow‐up data were collected bimonthly until month 12, after which data were collected on a quarterly basis. Baseline blood pressure values (mean±standard deviation) were 185±18/107±13 mm Hg in the office and 152±17/93±11 mm Hg through 24‐hour ambulatory blood pressure monitoring (ABPM). Three patients with stage 4 CKD required chronic renal replacement therapy (one at the 13‐month follow‐up and two at the 14‐month follow‐up) after episodes of acute renal injury; their follow‐up was subsequently discontinued. The office blood pressure values at the 24‐month follow‐up were 131±15/87±9 mm Hg (P<.0001, for both comparisons); the corresponding ABPM values were 132±14/84±12 mm Hg (P<.0001, for both comparisons). The mean estimated glomerular filtration rate increased from 61.9±23.9 mL/min/1.73 m2 to 88.0±39.8 mL/min/1.73 m2 (P<.0001). The urine albumin:creatinine ratio decreased from 99.8 mg/g (interquartile range, 38.0–192.1) to 11.0 mg/g (interquartile range, 4.1–28.1; P<.0001 mg/g). At the end of the follow‐up period, 21 patients (70% of the initial sample) were no longer classified as having CKD.

Pulmonary vein isolation alone and combined with renal sympathetic denervation in chronic kidney disease patients with refractory atrial fibrillation

“…We believe that this overactivity from the essential hypertensive state is in part controlled by antihypertensive drugs because patients maintain a normotensive state, leaving only sympathetic hyperactivity due to CKD. The interruption of this vicious feedback cycle, which reduces this sympathetic overactivity and the feedback loop of the renin–angiotensin–aldosterone system [35], may at least in part account for our findings regarding eGFR improvement and albuminuria reduction after RSD, even lower than previously reported results [24], [7].…”

“…This new procedure exposed no severe vascular or renal complications in the long term (up to 36 months). RSD is proving to be a worthwhile procedure in patients with CKD at different stages, improving the renal function, reducing the BP, the left ventricular (LV) mass and also the sympathetic nerve activity [6], [7], [8], [9]. Our group believes that RSD can reduce AF recurrence in patients with CKD by modulation of the sympathetic hyperactivity present in this disease.…”

Synergy of pulmonary vein isolation and catheter renal denervation in atrial fibrillation complicated with uncontrolled hypertension: Mapping the renal sympathetic nerve and pulmonary vein (the pulmonary vein isolation plus renal denervation strategy)?

“…Renal sympathetic nervous activity represents a pivotal neurogenic mechanism in hypertension. The concept of RDN as a catheter‐based treatment technique aiming at better BP control by modulating sympathetic nervous activity has been proposed and intensively researched …”

Renal Denervation for the Hypertension of Chronic Kidney Disease: A Special Case?

“…Assessment of denervation efficacy with renal norepinephrine spillover measurements in clinical studies reflects this, where it has been documented that achieved denervation differs markedly between individual patients, sometimes up to <25% . Given this unpredictability concerning the number of RF energy applications, it appears that “the more the merrier.” The authors here also attribute particular benefit to the catheter used, specifically that it utilized irrigated cooling and had an electrode larger than usual, which could be additional pertinent factors.…”

“…Perhaps most surprising in the present trial was the extent of the beneficial effect of RDN on the kidney, the improvement in GFR and microalbuminuria being such that, in the words of the authors, “at the end of the 24‐month follow‐up period, 21 patients (70% of the sample) could no longer be classified as having CKD.” What does the observed improvement in CKD grade represent? Is this attributable to beneficial prerenal influences on GFR from the reduction in antihypertensive dosing?…”