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Shinohara K. Renal denervation: a key approach to hypertension and cardiovascular disease. Hypertens Res 2024; 47:2671-2677. [PMID: 38961280 DOI: 10.1038/s41440-024-01776-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 05/13/2024] [Accepted: 06/06/2024] [Indexed: 07/05/2024]
Abstract
Sympathetic activation plays a critical role in the development of hypertension and cardiovascular disease, including heart failure and arrhythmias. Renal nerves contribute to the regulation of blood pressure and fluid volume through renal sympathetic efferent nerves, and to the modulation of sympathetic outflow through renal sensory afferent nerves. Previous studies including ours suggest that selective afferent renal denervation with preservation of efferent renal nerves can significantly decrease central sympathetic outflow in animal models of hypertension with renal damage. In Dahl salt-sensitive rats fed high salt diet from an early age, a model of hypertensive heart failure, this central sympathoinhibition by afferent renal denervation may attenuate the development of heart failure without significant blood pressure reduction. Accumulating clinical evidence supports the efficacy of renal denervation as an antihypertensive treatment. However, it remains important to clarify the appropriate indications and predictors of responders to renal denervation in the treatment of hypertension. Several clinical studies suggest beneficial effects of renal denervation in patients with heart disease, with or without hypertension, although most were not sham-controlled. In particular, some clinical studies have demonstrated that renal denervation reduces the incidence of atrial fibrillation or cardiovascular events even without a significant antihypertensive effect. It is essential to accumulate more insightful data in patients undergoing renal denervation, to establish the efficacy of renal denervation in patients with cardiovascular disease in the clinical setting, and to elucidate the therapeutic mechanisms of renal denervation and the renal nerves-linked pathophysiology of cardiovascular disease in basic research. This review outlines the effects of renal denervation on sympathetic activity and organ damage in animal models of hypertension and hypertensive heart failure, including our own data. Beyond the antihypertensive effects, the beneficial effects of renal denervation on cardiovascular disease are also discussed based on clinical studies. Several animal and clinical studies suggest the cardioprotective effects of renal denervation even in the absence of significant blood pressure reduction, probably due to its sympathoinhibitory effects.
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Affiliation(s)
- Keisuke Shinohara
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Kusayama T, Nagamori Y, Takeuchi K, Nakagawa Y, Takamura M. Renal autonomic dynamics in hypertension: how can we evaluate sympathetic activity for renal denervation? Hypertens Res 2024; 47:2685-2692. [PMID: 39095482 DOI: 10.1038/s41440-024-01816-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 06/10/2024] [Accepted: 06/29/2024] [Indexed: 08/04/2024]
Abstract
This review explores the various pathophysiological factors influencing antihypertensive effects, involving the regulation of vascular resistance, plasma volume, cardiac function, and the autonomic nervous system, emphasizing the interconnected processes regulating blood pressure (BP). The kidney's pivotal role in BP control and its potential contribution to hypertension is complicated but important to understand the effective mechanisms of renal denervation (RDN), which may be a promising treatment for resistant hypertension. Excessive stimulation of the sympathetic nervous system or the renin-angiotensin-aldosterone system (RAAS) can elevate BP through various physiological changes, contributing to chronic hypertension. Renal sympathetic efferent nerve activation leads to elevated norepinephrine levels and subsequent cascading effects on vasoconstriction, renin release, and sodium reabsorption. RDN reduces BP in resistant hypertension by potentially disrupting sensory afferent nerves, decreasing feedback activation to the central nervous system, and reducing efferent sympathetic nerve activity in the heart and other structures. RDN may also modulate central sympathetic outflow and inhibit renal renin-angiotensin system overactivation. While evidence for RDN efficacy in hypertension is increasing, accurate patient selection becomes crucial, considering complex interactions that vary among patients. This review also discusses methods to evaluate autonomic nerve activity from the golden standard to new potential examination for finding out optimization in stimulation parameters or rigorous patient selection based on appropriate biomarkers.
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Affiliation(s)
- Takashi Kusayama
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kanazawa University, Ishikawa, Japan.
| | - Yuta Nagamori
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kanazawa University, Ishikawa, Japan
| | - Kazutaka Takeuchi
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kanazawa University, Ishikawa, Japan
| | - Yoichiro Nakagawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kanazawa University, Ishikawa, Japan
| | - Masayuki Takamura
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kanazawa University, Ishikawa, Japan
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Shinohara K. Beneficial effects of renal denervation on heart, kidneys, and adipose tissue beyond antihypertensive effect: is it independent of systemic sympathetic activity? Hypertens Res 2024; 47:2776-2777. [PMID: 38720029 DOI: 10.1038/s41440-024-01689-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 03/31/2024] [Indexed: 10/08/2024]
Affiliation(s)
- Keisuke Shinohara
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Maini AS, Maini M, Addo T, Koshti V, Koshy T, de Lemos JA, Price A, Kumbhani DJ. The Current State and Future of Renal Denervation: A Review. Trends Cardiovasc Med 2024:S1050-1738(24)00078-1. [PMID: 39208954 DOI: 10.1016/j.tcm.2024.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Revised: 08/08/2024] [Accepted: 08/24/2024] [Indexed: 09/04/2024]
Abstract
Renal denervation as an option for difficult to treat hypertension has been a concept for several decades, with recent U.S. FDA approval of new, minimally invasive devices. However, while renal denervation has the potential to improve hypertension management, several challenges require consideration prior to widespread adoption. The effect relative to sham control is modest, and generally similar to addition of a single blood pressure lowering medication. It is possible that with additional technique refinement greater effects may be possible. Key factors to consider beyond the direction, strengths, and limitations of the renal denervation technologies themselves, are an understanding of patient groups that derive greatest benefit and phenotypes or biomarkers that predict greater response. This review provides an update on these challenges in addition to the current state and future of renal denervation within the context of hypertension management and treatment.
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Affiliation(s)
- Aneel S Maini
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
| | - Mansi Maini
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Tayo Addo
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Vivek Koshti
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Thomas Koshy
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - James A de Lemos
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Angela Price
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Dharam J Kumbhani
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Kitada K. Do tissue sodium levels support renal denervation? Hypertens Res 2024; 47:372-374. [PMID: 37985743 DOI: 10.1038/s41440-023-01513-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 10/23/2023] [Accepted: 10/24/2023] [Indexed: 11/22/2023]
Affiliation(s)
- Kento Kitada
- Department of Pharmacology, Faculty of Medicine, Kagawa University, Kagawa, 7610793, Japan.
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Jelaković B, Perkov D, Barišić K, Bukal N, Gellineo L, Jelaković A, Josipović J, Prkačin I, Željković Vrkić T, Živko M. Renal Denervation in the Treatment of Resistant Hypertension and Difficult-to-Control Hypertension - Consensus Document of the Croatian Hypertension League - Croatian Society of Hypertension, Croatian Cardiac Society, Croatian Endovascular Initiative, Croatian Society for Diabetes and Metabolic Diseases, Croatian Renal Association, and Croatian Society of Family Physicians of the Croatian Medical Association. Vasc Health Risk Manag 2023; 19:805-826. [PMID: 38108022 PMCID: PMC10724019 DOI: 10.2147/vhrm.s422773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/21/2023] [Indexed: 12/19/2023] Open
Abstract
Renal denervation (RDN) as a method of treating arterial hypertension (AH) was introduced in Croatia in 2012. A multidisciplinary team and a network of hospitals that diagnose and treat patients with severe forms of AH were established, and a very strict diagnostic-treatment algorithm was prepared. At monthly meetings patients with truly resistant hypertension who were candidates for RDN were discussed. According to the 2021 ESH position statement and 2023 ESH guidelines, RDN is considered an alternative and additional, not a competitive method of treating patients with various forms of AH which must be performed by following a structured procedure and the patient's preference should be considered. In view of the changes in the global scientific community, the Croatian Hypertension League brings this consensus document on RDN conducted with radiofrequency-based catheter, the only currently available method in Croatia. In this document, exclusion and inclusion criteria are shown, as well as three groups of patients in whom RDN could be considered. The new diagnostic-treatment algorithm is prepared and follow-up procedure is explained. In Croatia, RDN is reimbursed by the national insurance company, thus pharmacoeconomic analyses is also shown. Criteria required by an individual centre to be approved of RDN are listed, and plans for prospective research on RDN in Croatia, including the Croatian registry for RDN, are discussed.
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Affiliation(s)
- Bojan Jelaković
- School of Medicine University of Zagreb, Zagreb, Croatia
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Dražen Perkov
- Department of Diagnostic and Interventional Radiology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Klara Barišić
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Nikolina Bukal
- Department of Internal Medicine, Nephrology and Pulmonology, General Hospital “Dr. J. Benčević”, Slavonski Brod, Croatia
| | - Lana Gellineo
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Ana Jelaković
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Josipa Josipović
- Croatian Catholic University, Zagreb, Croatia
- Department of Nephrology and Dialysis, University Hospital Centre Sestre Milosrdnice, Zagreb, Croatia
| | - Ingrid Prkačin
- Department for Emergency Medicine, Clinical Hospital Merkur, Zagreb, Croatia
| | | | - Marijana Živko
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - On the behalf of Task force for the Resistant Hypertension and Renal Denervation of the Croatian Hypertension League
- School of Medicine University of Zagreb, Zagreb, Croatia
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
- Department of Diagnostic and Interventional Radiology, University Hospital Centre Zagreb, Zagreb, Croatia
- Department of Internal Medicine, Nephrology and Pulmonology, General Hospital “Dr. J. Benčević”, Slavonski Brod, Croatia
- Croatian Catholic University, Zagreb, Croatia
- Department of Nephrology and Dialysis, University Hospital Centre Sestre Milosrdnice, Zagreb, Croatia
- Department for Emergency Medicine, Clinical Hospital Merkur, Zagreb, Croatia
- Institute for Cardiovascular Prevention and Rehabilitation, Zagreb, Croatia
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Shinohara K. Celiac ganglia: potential new targets in neuromodulation for hypertension. Hypertens Res 2023; 46:2235-2236. [PMID: 37344634 DOI: 10.1038/s41440-023-01355-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/02/2023] [Accepted: 06/06/2023] [Indexed: 06/23/2023]
Affiliation(s)
- Keisuke Shinohara
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Vogt A, Dutzmann J, Nußbaum M, Hoyer D, Tongers J, Schlitt A, Sedding D, Plehn A. Safety and efficacy of renal sympathetic denervation: a 9-year long-term follow-up of 24-hour ambulatory blood pressure measurements. Front Cardiovasc Med 2023; 10:1210801. [PMID: 37404730 PMCID: PMC10315532 DOI: 10.3389/fcvm.2023.1210801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 05/26/2023] [Indexed: 07/06/2023] Open
Abstract
Background Renal sympathetic denervation (RDN) has been shown to lower arterial blood pressure both in the presence and in the absence of antihypertensive medication in an observation period of up to 3 years. However, long-term results beyond 3 years are scarcely reported. Methods We performed a long-term follow-up on patients who were previously enrolled in a local renal denervation registry and who underwent radiofrequency RDN with the Symplicity Flex® renal denervation system between 2011 and 2014. The patients were assessed to evaluate their renal function by performing 24-hour ambulatory blood pressure measurement (ABPM), recording their medical history, and conducting laboratory tests. Results Ambulatory blood pressure readings for 24 h were available for 72 patients at long-term follow-up (FU) [9.3 years (IQR: 8.5-10.1)]. We found a significant reduction of ABP from 150.1/86.1 ± 16.9/12.0 mmHg at baseline to 138.3/77.1 ± 16.5/11.1 mmHg at long-term FU (P < 0.001 for both systolic and diastolic ABP). The number of antihypertensive medications used by the patients significantly decreased from 5.4 ± 1.5 at baseline to 4.8 ± 1.6 at long-term FU (P < 0.01). Renal function showed a significant but expected age-associated decrease in the eGFR from 87.8 (IQR: 81.0-100.0) to 72.5 (IQR: 55.8-86.8) ml/min/1.73 m2 (P < 0.01) in patients with an initial eGFR > 60 ml/min/1.73 m2, while a non-significant decrease was observed in patients with an initial eGFR < 60 ml/min/1.73 m2 at long-term FU [56.0 (IQR: 40.9-58.4) vs. 39.0 (IQR: 13.5-56.3) ml/min/1.73 m2]. Conclusions RDN was accompanied by a long-lasting reduction in blood pressure with a concomitant reduction in antihypertensive medication. No negative effects could be detected, especially with regard to renal function.
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Affiliation(s)
- Alexander Vogt
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Jochen Dutzmann
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Michael Nußbaum
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Daniel Hoyer
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Jörn Tongers
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Axel Schlitt
- Department of Cardiology and Diabetes, Paracelsus-Harz-Clinic Bad Suderode, Quedlinburg, Germany
| | - Daniel Sedding
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Alexander Plehn
- Department of Internal Medicine III, University Hospital Halle (Saale), Halle (Saale), Germany
- Praxisklinik Salzatal, Salzatal, Germany
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