Renal denervation in treatment-resistant hypertension: a reappraisal

Persu, Alexandre; Jin, Yu; Elmula, Fadl Elmula M. Fadl; Renkin, Jean; Høieggen, Aud; Kjeldsen, Sverre E.; Staessen, Jan A.

doi:10.1016/j.coph.2014.12.013

Cited by 14 publications

(8 citation statements)

References 37 publications

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“…[3][4][5] However, failure of the RDN to lower blood pressure (BP) over and above the sham control group in the large randomized double-blinded Symplicity HTN-3 trial 6 has raised doubt about the efficacy of the technique. 7 Besides crucial design differences between Symplicity HTN-3 and previous, unblinded and mostly observational studies, 8 the disappointing results of Symplicity HTN-3 may have been partly because of insufficient renal ablation. 9,10 The possible role of insufficient renal ablation is further highlighted by the demonstration of a lesser response to RDN in patients with multiple 11 and accessory 12 renal arteries, which may contribute to the large variability of response observed after RDN.…”

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confidence: 99%

Persistent Increase in Blood Pressure After Renal Nerve Stimulation in Accessory Renal Arteries After Sympathetic Renal Denervation

et al. 2016

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Recently, we showed that BP increase elicited by high-frequency renal nerve stimulation (RNS) is significantly blunted after RDN. 15 This approach may allow to gain further insights into the differences in BP response to RDN in patient with or without renal accessory arteries. We hypothesized that after successful RDN, there will be no significant increase in BP after RNS in the main arteries, whereas there will still be an increase in BP in response to RNS in the accessory arteries. To See Editorial Commentary, pp 1117-1118Abstract-Blood pressure response to renal denervation is highly variable, and the proportion of responders is disappointing.This may be partly because of accessory renal arteries too small for denervation, causing incomplete ablation. Renal nerve stimulation before and after renal denervation is a promising approach to assess completeness of renal denervation and may predict blood pressure response to renal denervation. The objective of the current study was to assess renal nerve stimulation-induced blood pressure increase before and after renal sympathetic denervation in main and accessory renal arteries of anaesthetized patients with drug-resistant hypertension. The study included 21 patients. Nine patients had at least 1 accessory renal artery in which renal denervation was not feasible. Renal nerve stimulation was performed in the main arteries of all patients and in accessory renal arteries of 6 of 9 patients with accessory arteries, both before and after renal sympathetic denervation. Renal nerve stimulation before renal denervation elicited a substantial increase in systolic blood pressure, both in main (25.6±2.9 mm Hg; P<0.001) and accessory (24.3±7.4 mm Hg; P=0.047) renal arteries. After renal denervation, renal nerve stimulation-induced systolic blood pressure increase was blunted in the main renal arteries (Δ systolic blood pressure, 8.6±3.7 mm Hg; P=0.020), but not in the nondenervated renal accessory renal arteries (Δ systolic blood pressure, 27.1±7.6 mm Hg; P=0.917). This residual source of renal sympathetic tone may result in persistent hypertension after ablation and partly account for the large response variability. (Hypertension.

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confidence: 99%

Persistent Increase in Blood Pressure After Renal Nerve Stimulation in Accessory Renal Arteries After Sympathetic Renal Denervation

et al. 2016

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“…Finally, so-called TRH sometimes merely is regarded as undertreated hypertension. 7,8 Therefore, we studied whether the prevalence of TRH declines after several years of close follow-up.…”

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Prevalence of Apparent Therapy-Resistant Hypertension and Its Effect on Outcome in Patients With Chronic Kidney Disease

et al. 2015

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New options recently became available for treatment of uncontrolled blood pressure. Information on the prevalence of therapy-resistant hypertension (TRH) in patients with chronic kidney disease and its consequences is relevant to balance risks and benefits of potential new therapies. Data of 788 patients with chronic kidney disease came from a multicenter study investigating the effect on outcome of an integrated multifactorial approach delivered by nurse practitioners added to usual care versus usual care alone. Blood pressure was measured at the office and during 30 minutes using an automated oscillometric device. Apparent TRH (aTRH) was defined as a blood pressure ≥130/80 mm Hg despite treatment with ≥3 antihypertensive drugs, including a diuretic or treatment with ≥4 antihypertensive drugs. Participants were followed up for the occurrence of myocardial infarction, stroke or cardiovascular mortality (composite cardiovascular end point) and end-stage renal disease. aTRH was present in 34% (office blood pressure) and in 32% (automated measurements). During 5.3 years of follow-up, 17% of patients with aTRH reached a cardiovascular end point and 27% reached end-stage renal disease. aTRH lead to a 1.5-fold higher risk (95% confidence interval, 0.8–3.0) of a cardiovascular end point compared with controlled hypertensives in multivariable-adjusted analysis. aTRH increased end-stage renal disease risk 2.3-fold (95% confidence interval, 1.4–3.7). During 4 years of follow-up, the prevalence of aTRH did not decline in either treatment group. The prevalence of aTRH is high in patients with chronic kidney disease even after optimization of nephrologist care. The presence of TRH is related to a substantially increased risk of renal and cardiovascular outcomes.

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“…3 Overall, these different RCTs failed to replicate the impressive results of SYMPLICITY HTN-2, 5 which were probably substantially overestimated due to a number of patient-and physician-related biases. [10][11][12][13] The results of a recent sham-controlled RCT 14 using the Symplicity Flex catheter (Medtronic Inc) are in the same line, with a non-significant 4 mm Hg reduction in systolic ABPM for RDN over control. Still, taken together, the recent RCTs [1][2][3][4]14 are compatible with some BP-lowering effect of RDN-as pointed out above corresponding to the effect of one antihypertensive drug.…”

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confidence: 67%