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Lo HY, Lee JK, Lin YH. The feasibility, efficacy, and safety of RDN procedure using CO 2 angiography through radial artery in severe chronic kidney disease patients. Hypertens Res 2024; 47:760-766. [PMID: 38177288 DOI: 10.1038/s41440-023-01540-3] [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: 09/15/2023] [Revised: 11/14/2023] [Accepted: 11/18/2023] [Indexed: 01/06/2024]
Abstract
The recent evidence regarding the effectiveness of renal denervation (RDN) in blood pressure control is becoming increasingly substantial. However, many studies have excluded populations with severely impaired kidney function, even though these individuals have a higher prevalence of hypertension compared to the general population, and controlling their blood pressure is more challenging. The effectiveness and safety of RDN in patients with severe chronic kidney disease (CKD) lack strong evidence support. Concerns about worsening kidney function still exist, particularly in patients with CKD stage 5. We conducted an observational study involving 10 patients who were using at least 3 different antihypertensive medications and had an estimated glomerular filtration rate (eGFR) < 45 mL/min/1.73 m2 but had not undergone dialysis. For these patients, we performed RDN via the radial artery approach, with the assistance of carbon dioxide (CO2) angiography. Utilizing this approach, the systolic 24-hour ambulatory blood pressure monitoring did not exhibit a significant decrease at 3 months; however, a significant reduction was observed at 6 months after RDN. We also minimized contrast agent usage, observed no kidney function decline 3 months post-RDN, and experienced no vascular-related complications. Using the radial artery approach and CO2 angiography assistance for RDN may be an effective and safe blood pressure control method for patients with severe kidney impairment.
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Affiliation(s)
- Hao-Yun Lo
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Jen-Kuang Lee
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
- National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Yen-Hung Lin
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- National Taiwan University College of Medicine, Taipei, Taiwan
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Scalise F, Quarti-Trevano F, Toscano E, Sorropago A, Vanoli J, Grassi G. Renal Denervation in End-Stage Renal Disease: Current Evidence and Perspectives. High Blood Press Cardiovasc Prev 2024; 31:7-13. [PMID: 38267652 PMCID: PMC10925565 DOI: 10.1007/s40292-023-00621-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 12/22/2023] [Indexed: 01/26/2024] Open
Abstract
In patients with end-stage renal disease (ESRD) undergoing haemodialysis, hypertension is of common detection and frequently inadequately controlled. Multiple pathophysiological mechanisms are involved in the development and progression of the ESRD-related high blood pressure state, which has been implicated in the increased cardiovascular risk reported in this hypertensive clinical phenotype. Renal sympathetic efferent and afferent nerves play a relevant role in the development and progression of elevated blood pressure values in patients with ESRD, often leading to resistant hypertension. Catheter-based bilateral renal nerves ablation has been shown to exert blood pressure lowering effects in resistant hypertensive patients with normal kidney function. Promising data on the procedure in ESRD patients with resistant hypertension have been reported in small scale pilot studies. Denervation of the native non-functioning kidney's neural excitatory influences on central sympathetic drive could reduce the elevated cardiovascular morbidity and mortality seen in ESRD patients. The present review article will focus on the promising results obtained with renal denervation in patients with ESRD, its mechanisms of action and future perspectives in these high risk patients.
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Affiliation(s)
- Filippo Scalise
- Department of Interventional Cardiology, Policlinico di Monza, Monza, Italy
| | - Fosca Quarti-Trevano
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20052, Monza, Milan, Italy
| | - Evelina Toscano
- Department of Interventional Cardiology, Policlinico di Monza, Monza, Italy
| | - Antonio Sorropago
- Department of Interventional Cardiology, Policlinico di Monza, Monza, Italy
| | - Jennifer Vanoli
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20052, Monza, Milan, Italy
| | - Guido Grassi
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20052, Monza, Milan, Italy.
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3
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Rebrova TY, Falkovskaya AY, Afanasiev SA, Mordovin VF, Zyubanova IV, Muslimova EF. [Five-year dynamics adrenergic reactivity of erythrocytes after radio-frequency sympathic denervation of renal arteries in patients with resistant arterial hypertension]. TERAPEVT ARKH 2023; 95:757-762. [PMID: 38158918 DOI: 10.26442/1560-4071-2020-1-3677] [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: 01/18/2022] [Indexed: 01/03/2024]
Abstract
AIM To study the initial state of adrenergic reactivity and the five-year dynamics of the beta-adrenergic reactivity index of erythrocyte membranes and the manifestation of the antihypertensive effect of the procedure for radiofrequency destruction of sympathetic structures of the renal artery in patients with resistant arterial hypertension. SUBJECTS AND METHODS The analysis included 42 patients with resistant arterial hypertension (RH). The renal denervation (RD) procedure of the kidneys was performed by endovascular bilateral transcatheter radiofrequency ablation of the renal arteries. The study of 24-hour blood pressure monitoring (BPM) and the determination of β-adrenoreactivity of erythrocytes (β-ARM) by changes in the osmoresistance of erythrocyte membranes were performed initially, 1 week, 6 months, 1, 2, 3 and 5 years after RD. Patients retrospectively, at a follow-up period of 6 months after RD, were divided into responders (decrease in blood pressure by 10 or more mm Hg) and non-responders (decrease in blood pressure less than 10 mm Hg). RESULTS 6 months after the RD, the number of responders was 28 people (66.7%), after 5 years - 31 people (73.8%). At the time of inclusion in the study, the median β-ARM in the group of non-responders was not significantly higher than in the group of responders. After 6 months after the RD procedure, the β-ARM indicator in the non-responder group was significantly lower than in the responder group (p = 0.043). With further follow-up in the group of responders, an increase in the median β-ARM was noted, which reached significant differences relative to the baseline values in the group at follow-up periods of 1 year (p = 0.036) and 5 years (p = 0.004) after RD. The change in the β-ARM indicator in the non-responder group was wavy in nature, the changes did not reach the significance criteria. CONCLUSION Renal denervation in 73.8% of cases is accompanied by a stable antihypertensive response for 5 years of observation and an increase in β-ARM, which may indicate the implementation of compensatory mechanisms in conditions of increasing activity of the sympathoadrenal system in response to a decrease in blood pressure.
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Mujadzic H, Mehta ND, Battle SJ, DiPette DJ. Editorial commentary: Renal denervation for hypertension: A new meta-analysis promotes further discussion. Trends Cardiovasc Med 2023; 33:499-501. [PMID: 35777595 DOI: 10.1016/j.tcm.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 06/26/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Hata Mujadzic
- Department of Internal Medicine, Prisma Health/University of South Carolina and University of South Carolina School of Medicine, 2 Medical Park Road, Suite 402, 29203, Columbia, SC, United States
| | - Neil D Mehta
- Department of Internal Medicine, Prisma Health/University of South Carolina and University of South Carolina School of Medicine, 2 Medical Park Road, Suite 402, 29203, Columbia, SC, United States
| | - Sean J Battle
- Department of Internal Medicine, Prisma Health/University of South Carolina and University of South Carolina School of Medicine, 2 Medical Park Road, Suite 402, 29203, Columbia, SC, United States
| | - Donald J DiPette
- Department of Internal Medicine, University of South Carolina and University of South Carolina School of Medicine, 2 Medical Park Road, Suite 402, 29203, Columbia, South Carolina, United States.
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5
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Grassi G. Sympathetic modulation as a goal of antihypertensive treatment: from drugs to devices. J Hypertens 2023; 41:1688-1695. [PMID: 37602470 PMCID: PMC10552843 DOI: 10.1097/hjh.0000000000003538] [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: 06/19/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 08/22/2023]
Abstract
The present study aims to examine the effects of nonpharmacological, pharmacological and devices-based treatment on hypertension-related sympathetic overactivity. This will be done by analyzing the results of different published studies, in which sympathetic activity has been assessed via indirect or direct techniques. After examining the rationale for sympathomodulatory interventions in antihypertensive treatment, the study will discuss the methodological intrinsic limitations of the studies aimed at assessing different therapeutic interventions. The core of the study will be then focused on the effects of nonpharmacological (dietary restriction of sodium intake, physical exercise training, weight reduction), pharmacological (monotherapy, combination drug treatment, new drugs such as sodium glucose co-transport protein-2 inhibitors and angiotensin receptor neprilysin inhibitors), as well as devices-based interventions (renal sympathetic nerves ablation and carotid baroreceptor activation therapy) on the hypertension-related sympathetic overdrive. Finally, the areas worthy of future research as well as the debated issues in the field will be highlighted.
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Affiliation(s)
- Guido Grassi
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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Collard D, Velde LVD, Stegehuis VE, Delewi R, Beijk MAM, Zijlstra IJAJ, de Winter RJ, Vogt L, van den Born BJH. Assessment of renal sympathetic control using invasive pressure and flow velocity measurements in humans. Am J Physiol Renal Physiol 2023; 325:F263-F270. [PMID: 37382495 DOI: 10.1152/ajprenal.00031.2023] [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: 02/16/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 06/30/2023] Open
Abstract
Renal sympathetic innervation is important in the control of renal and systemic hemodynamics and is a target for pharmacological and catheter-based therapies. The effect of a physiological sympathetic stimulus using static handgrip exercise on renal hemodynamics and intraglomerular pressure in humans is unknown. We recorded renal arterial pressure and flow velocity in patients with a clinical indication for coronary or peripheral angiography using a sensor-equipped guidewire during baseline, handgrip, rest, and hyperemia following intrarenal dopamine (30 μg/kg). Changes in perfusion pressure were expressed as the change in mean arterial pressure, and changes in flow were expressed as a percentage with respect to baseline. Intraglomerular pressure was estimated using a Windkessel model. A total of 18 patients (61% male and 39% female) with a median age of 57 yr (range: 27-85 yr) with successful measurements were included. During static handgrip, renal arterial pressure increased by 15.2 mmHg (range: 4.2-53.0 mmHg), whereas flow decreased by 11.2%, but with a large variation between individuals (range: -13.4 to 49.8). Intraglomerular pressure increased by 4.2 mmHg (range: -3.9 to 22.1 mmHg). Flow velocity under resting conditions remained stable, with a median of 100.6% (range: 82.3%-114.6%) compared with baseline. During hyperemia, maximal flow was 180% (range: 111%-281%), whereas intraglomerular pressure decreased by 9.6 mmHg (interquartile range: 4.8 to 13.9 mmHg). Changes in renal pressure and flow during handgrip exercise were significantly correlated (ρ = -0.68, P = 0.002). Measurement of renal arterial pressure and flow velocity during handgrip exercise allows the identification of patients with higher and lower sympathetic control of renal perfusion. This suggests that hemodynamic measurements may be useful to assess the response to therapeutic interventions aimed at altering renal sympathetic control.NEW & NOTEWORTHY Renal sympathetic innervation is important in the homeostasis of systemic and renal hemodynamics. We showed that renal arterial pressure significantly increased and that flow decreased during static handgrip exercise using direct renal arterial pressure and flow measurements in humans, but with a large difference between individuals. These findings may be useful for future studies aimed to assess the effect of interventions that influence renal sympathetic control.
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Affiliation(s)
- Didier Collard
- Department of Internal Medicine, Section Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Lennart van de Velde
- Department of Internal Medicine, Section Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Faculty of Science and Technology, Technical Medical Centre, Multi-Modality Medical Imaging Group, University of Twente, Enschede, The Netherlands
| | - Valerie E Stegehuis
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ronak Delewi
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcel A M Beijk
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - IJsbrand A J Zijlstra
- Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Robbert J de Winter
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Liffert Vogt
- Department of Internal Medicine, Section Nephrology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bert-Jan H van den Born
- Department of Internal Medicine, Section Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Collard D, Velde LVD, Stegehuis VE, Delewi R, Beijk MAM, Zijlstra IJAJ, de Winter RJ, Vogt L, van den Born BJH. Assessment of renal sympathetic control using invasive pressure and flow velocity measurements in humans. Am J Physiol Renal Physiol 2023; 325:F263-F270. [DOI: https:/doi.org/10.1152/ajprenal.00031.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 11/30/2023] Open
Abstract
Renal sympathetic innervation is important in the homeostasis of systemic and renal hemodynamics. We showed that renal arterial pressure significantly increased and that flow decreased during static handgrip exercise using direct renal arterial pressure and flow measurements in humans, but with a large difference between individuals. These findings may be useful for future studies aimed to assess the effect of interventions that influence renal sympathetic control.
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Affiliation(s)
- Didier Collard
- Department of Internal Medicine, Section Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Lennart van de Velde
- Department of Internal Medicine, Section Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Faculty of Science and Technology, Technical Medical Centre, Multi-Modality Medical Imaging Group, University of Twente, Enschede, The Netherlands
| | - Valerie E. Stegehuis
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ronak Delewi
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcel A. M. Beijk
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Robbert J. de Winter
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Liffert Vogt
- Department of Internal Medicine, Section Nephrology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bert-Jan H. van den Born
- Department of Internal Medicine, Section Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Biffi A, Dell'Oro R, Quarti-Trevano F, Cuspidi C, Corrao G, Mancia G, Grassi G. Effects of Renal Denervation on Sympathetic Nerve Traffic and Correlates in Drug-Resistant and Uncontrolled Hypertension: A Systematic Review and Meta-Analysis. Hypertension 2023; 80:659-667. [PMID: 36628971 DOI: 10.1161/hypertensionaha.122.20503] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Whether and to what extent the reported blood pressure (BP) lowering effects of renal denervation (RDN) are associated with a central sympathoinhibition is controversial. We examined this issue by performing a meta-analysis of the microneurographic studies evaluating the BP and muscle sympathetic nerve activity (MSNA) responses to RDN in drug-resistant or uncontrolled hypertension (RHT). METHODS This analysis comprised 11 studies including a total of >400 RHT patients undergoing RDN and were followed up for 6 months. Evaluation was extended to the relationships of MSNA with clinic heart rate and BP changes associated with RDN. RESULTS MSNA showed a significant reduction after RDN (-4.78 bursts/100 heart beats; P<0.04), which was also accompanied by a significant systolic (-11.45 mm Hg; P<0.002) and diastolic (-5.24 mm Hg; P=0.0001) BP decrease. No significant quantitative relationship was found between MSNA and systolic (r=-0.96, P=0.19) or diastolic BP (r=-0.97, P=0.23) responses to RDN. This was also the case for clinic heart rate (r=0.53, P=0.78, respectively), whose post RDN values were not significant different from the pre-RDN ones. More than 10 renal nerves ablations were found to be needed for obtaining a significant sympathoinhibition. CONCLUSIONS This meta-analysis, the first ever done on the MSNA responses to RDN, shows that in a consistent number of RHT patients RDN is associated with a significant, although modest, central sympathoinhibition, which appears to be unrelated to the BP lowering effects of the procedure. Thus factors other than the central sympathetic outflow inhibition may concur at the BP lowering effects of RDN.
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Affiliation(s)
- Annalisa Biffi
- Department of Statistics and Quantitative Methods (A.B., G.C.), University Milano-Bicocca, Italy.,Na-National Centre for Healthcare Research and Pharmacoepidemiology (A.B., G.C.), University Milano-Bicocca, Italy
| | - Raffaella Dell'Oro
- Clinica Medica, Department of Medicine and Surgery (R.D.O., F.Q.-T., C.C., G.M., G.G.), University Milano-Bicocca, Italy
| | - Fosca Quarti-Trevano
- Clinica Medica, Department of Medicine and Surgery (R.D.O., F.Q.-T., C.C., G.M., G.G.), University Milano-Bicocca, Italy
| | - Cesare Cuspidi
- Clinica Medica, Department of Medicine and Surgery (R.D.O., F.Q.-T., C.C., G.M., G.G.), University Milano-Bicocca, Italy
| | - Giovanni Corrao
- Department of Statistics and Quantitative Methods (A.B., G.C.), University Milano-Bicocca, Italy.,Na-National Centre for Healthcare Research and Pharmacoepidemiology (A.B., G.C.), University Milano-Bicocca, Italy
| | - Giuseppe Mancia
- Clinica Medica, Department of Medicine and Surgery (R.D.O., F.Q.-T., C.C., G.M., G.G.), University Milano-Bicocca, Italy
| | - Guido Grassi
- Clinica Medica, Department of Medicine and Surgery (R.D.O., F.Q.-T., C.C., G.M., G.G.), University Milano-Bicocca, Italy
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Differential effects of renal denervation on skin and muscle sympathetic nerve traffic in resistant and uncontrolled hypertension. Clin Auton Res 2023; 33:93-100. [PMID: 36696071 PMCID: PMC10182930 DOI: 10.1007/s10286-023-00927-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/18/2023] [Indexed: 01/26/2023]
Abstract
PURPOSE Renal denervation (RDN) exerts sympathoinhibitory effects. No information is available, however, on whether these effects have a regional or a more generalized behavior. METHODS In 14 patients with resistant hypertension (RHT, age 58.3 ± 2.2 years, mean ± SEM), we recorded muscle and skin sympathetic nerve traffic (MSNA and SSNA, respectively) using the microneurographic technique, before, 1 month, and 3 months after RDN. Measurements included clinic blood pressure (BP), heart rate (HR), 24-h BP and HR, as well as routine laboratory and echocardiographic variables. Ten age-matched RHT patients who did not undergo RDN served as controls. RESULTS MSNA, but not SSNA, was markedly higher in RHT. RDN caused a significant reduction in MSNA 1 month after RDN, with this reduction increasing after 3 months (from 68.1 ± 2.5 to 64.8 ± 2.4 and 63.1 ± 2.6 bursts/100 heartbeats, P < 0.05). This effect was not accompanied by any significant change in SSNA (from 13.1 ± 0.5 to 13.4 ± 0.6 and 13.3 ± 0.4 bursts/min, P = NS). No quantitative or, in some cases, qualitative relationship was found between BP and the MSNA reduction induced by RDN. No significant changes in various sympathetic markers were detected in the control group who did not undergo RDN and were followed for 3-months observation. CONCLUSIONS These data provide the first evidence that RDN exerts heterogeneous effects on sympathetic cardiovascular drive, inducing a marked reduction in MSNA but not in SSNA, which appears to be within the normal range in this condition.These effects may depend on the different reflex modulation regulating neuroadrenergic drive in these cardiovascular districts.
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Yang X, Lin L, Zhang Z, Chen X. Effects of catheter-based renal denervation on renin-aldosterone system, catecholamines, and electrolytes: A systematic review and meta-analysis. J Clin Hypertens (Greenwich) 2022; 24:1537-1546. [PMID: 36321724 PMCID: PMC9731592 DOI: 10.1111/jch.14590] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 08/26/2022] [Accepted: 10/03/2022] [Indexed: 11/07/2022]
Abstract
In recent years, catheter-based renal denervation (RDN) has emerged as a promising instrumental therapy for hypertension. The interruption of sympathetic nervous system was regarded as a possible mechanism for RDN regulating blood pressure. While the results reflected by renin-angiotensin-aldosterone system (RAAS), catecholamines and electrolytes remained inconsistent and was never systematically assessed. Pubmed, Embase, and Web of Science were comprehensively searched from inception to September 5, 2021. Studies that evaluated the effects of RDN on RAAS, catecholamines, and electrolytes were identified. Primary outcomes were changes in RAAS hormones after RDN, and secondary outcomes involved changes in plasma norepinephrine, serum, and urinary sodium and potassium. Out of 6391 retrieved studies, 20 studies (two randomized controlled studies and 18 observational studies) involving 771 persons were eventually included. Plasma renin activity had a statistically significant reduction after RDN (0.24 ng/mL/h, 95% CI 0.04 to 0.44, P = .02). While no significant change was found regarding plasma aldosterone (1.53 ng/dL, 95% CI -0.61 to 3.67, P = .16), norepinephrine (0.42 nmol/L, 95% -0.51 to 1.35, P = 0.38), serum sodium and potassium (0.16 mmol/L, 95% CI -0.17 to 0.49, P = .34; -0.02 mmol/L, 95% CI -0.09 to 0.04, P = .48, respectively), and urinary sodium and potassium (3.95 mmol/24 h, 95% CI -29.36 to 37.26, P = .82; 10.22 mmol/24 h, 95% CI -12.11 to 32.54, P = .37, respectively). In conclusion, plasma renin activity significantly decreased after RDN, while no significant change was observed in plasma aldosterone, plasma norepinephrine, and serum and urinary electrolytes.
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Affiliation(s)
- Xiangyu Yang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lede Lin
- Department of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhipeng Zhang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoping Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
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11
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Rea F, Morabito G, Savaré L, Corrao G, Mancia G. The impact of renal denervation procedure on use of antihypertensive drugs in the real-life setting. Blood Press 2022; 31:245-253. [PMID: 36146925 DOI: 10.1080/08037051.2022.2126345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Purpose. Randomised controlled trials have shown that renal denervation lowers office and ambulatory blood pressure. The aim of the present study was to evaluate whether patients undergoing renal denervation procedure in a real-life setting have a reduction in antihypertensive drug prescription over the subsequent years.Material and methods. Using the healthcare utilisation database of the Lombardy Region (Italy), the 136 patients who, during the period 2011-2016, were prescribed four or more antihypertensive drugs and underwent renal denervation were included in the study cohort. The number and type of antihypertensive drugs were assessed over the year before and during the three-year period after renal denervation.Results. The median age of the patients was 67 years and 68% of them were men. Based on a multisource comorbidity score, about 40% of patients showed a poor or very poor clinical status. Before renal denervation, the majority of the patients were prescribed four or five antihypertensive drugs. The number of drugs decreased after the denervation and reached 55% after three years. Over the same period, patients prescribed six drugs decreased from 18% to 2%. All antihypertensive drugs were less prescribed throughout the post denervation period. Compared to the year before the denervation, after three years prescription of diuretics was reduced by 15%, calcium channel blockers by 21%, ACE-inhibitors by 32%, angiotensin receptor blockers by 22%, beta-blockers by 20%, and alfa-blockers by 30%. Use of antihypertensive drugs exhibited a reduction also in an age, sex, and clinically matched control group with no renal denervation to an extent, however, much lower than in denervated patients (p-value = 0.013).Conclusion. In the real-life setting, patients who underwent renal denervation had a clearcut reduction in antihypertensive drug prescription over the following years.Plain Language SummaryPatients exhibited a reduction in the prescription of antihypertensive drugs during the three years that followed the denervation procedureThe decrease in the number of antihypertensive drugs was marked, started after a relatively short time (six months), and involved all drugs prescribed before the denervationThe number of hospitalisations for a cardiovascular event was similar before and after renal denervationAlbeit blood pressure values were not recorded in our database, all these findings taken together suggest the renal denervation procedure has a favourable influence on blood pressure control and is not associated with an increase in the risk of major cardiovascular complications.
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Affiliation(s)
- Federico Rea
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.,Laboratory of Healthcare Research and Pharmacoepidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Gabriella Morabito
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.,Laboratory of Healthcare Research and Pharmacoepidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Laura Savaré
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.,MOX - Laboratory for Modeling and Scientific Computing, Department of Mathematics, Politecnico di Milano, Milan, Italy.,CHDS - Center for Health data Science, Human Technopole, Milan, Italy
| | - Giovanni Corrao
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.,Laboratory of Healthcare Research and Pharmacoepidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Giuseppe Mancia
- University of Milano-Bicocca (Emeritus Professor), Milan, Italy
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Huang H, Cheng H, Chia Y, Li Y, Van Minh H, Siddique S, Sukonthasarn A, Tay JC, Turana Y, Verma N, Kario K, Wang T. The role of renal nerve stimulation in percutaneous renal denervation for hypertension: A mini-review. J Clin Hypertens (Greenwich) 2022; 24:1187-1193. [PMID: 36196464 PMCID: PMC9532907 DOI: 10.1111/jch.14554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 07/11/2022] [Accepted: 07/18/2022] [Indexed: 11/19/2022]
Abstract
Recent trials have demonstrated the efficacy and safety of percutaneous renal sympathetic denervation (RDN) for blood pressure (BP)-lowering in patients with uncontrolled hypertension. Nevertheless, major challenges exist, such as the wide variation of BP-lowering responses following RDN (from strong response to no response) and lack of feasible and reproducible peri-procedural predictors for patient response. Both animal and human studies have demonstrated different patterns of BP responses following renal nerve stimulation (RNS), possibly related to varied regional proportions of sympathetic and parasympathetic nerve tissues along the renal arteries. Animal studies of RNS have shown that rapid electrical stimulation of the renal arteries caused renal artery vasoconstriction and increased norepinephrine secretion with a concomitant increase in BP, and the responses were attenuated after RDN. Moreover, selective RDN at sites with strong RNS-induced BP increases led to a more efficient BP-lowering effect. In human, when RNS was performed before and after RDN, blunted changes in RNS-induced BP responses were noted after RDN. The systolic BP response induced by RNS before RDN and blunted systolic BP response to RNS after RDN, at the site with maximal RNS-induced systolic BP response before RDN, both correlated with the 24-h ambulatory BP reductions 3-12 months following RDN. In summary, RNS-induced BP changes, before and after RDN, could be used to assess the immediate effect of RDN and predict BP reductions months following RDN. More comprehensive, large-scale and long term trials are needed to verify these findings.
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Affiliation(s)
- Hui‐Chun Huang
- Cardiovascular Center and Division of CardiologyDepartment of Internal MedicineNational Taiwan University HospitalNational Taiwan University College of MedicineTaipeiTaiwan
- Graduate Institute of Epidemiology and Preventive MedicineCollege of Public HealthNational Taiwan UniversityTaipeiTaiwan
| | - Hao‐min Cheng
- Department of MedicineTaipei Veterans General HospitalMedical Education and ResearchNational Yang‐Ming UniversityTaipeiTaiwan
| | - Yook‐Chin Chia
- Department of Medical SciencesSchool of Healthcare and Medical SciencesSunway UniversityBandar SunwayMalaysia
- Department of Primary Care MedicineFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Yan Li
- Department of Cardiovascular MedicineShanghai Institute of HypertensionShanghai Key Laboratory of HypertensionState Key Laboratory of Medical GenomicsNational Research Centre for Translational MedicineRuijin HospitalShanghai Jiaotong University School of MedicineShanghaiChina
| | - Huynh Van Minh
- Department of CardiologyUniversity of Medicine and PharmacyHue UniversityHue CityThua Thien‐HueVietnam
| | - Saulat Siddique
- Department of CardiologyFatima Memorial HospitalLahorePakistan
| | - Apichard Sukonthasarn
- Cardiology DivisionDepartment of Internal MedicineFaculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Jam Chin Tay
- Department of General MedicineTan Tock Seng HospitalSingaporeSingapore
| | - Yuda Turana
- Faculty of Medicine and Health SciencesAtma Jaya Catholic University of IndonesiaJakartaIndonesia
| | - Narsingh Verma
- Division of Cardiovascular MedicineDepartment of MedicineJichi Medical University School of MedicineShimotsukeTochigiJapan
| | - Kazuomi Kario
- Department of PhysiologyKing George's Medical UniversityLucknowIndia
| | - Tzung‐Dau Wang
- Cardiovascular Center and Division of CardiologyDepartment of Internal MedicineNational Taiwan University HospitalNational Taiwan University College of MedicineTaipeiTaiwan
- Division of Hospital MedicineDepartment of Internal MedicineNational Taiwan University HospitalNational Taiwan University College of MedicineTaipeiTaiwan
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13
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Schmieder RE. Renal denervation in patients with chronic kidney disease: current evidence and future perspectives. Nephrol Dial Transplant 2022; 38:1089-1096. [PMID: 35617138 PMCID: PMC10157753 DOI: 10.1093/ndt/gfac189] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Indexed: 11/14/2022] Open
Abstract
Supported by several high-quality randomised clinical trials and registry analyses, catheter-based renal denervation is becoming an important adjunctive treatment modality for the safe and efficacious treatment of hypertension besides lifestyle modifications and antihypertensive medication. Renal denervation is of particular interest to nephrologists as the intervention may provide additional benefits to hypertensive people with chronic kidney disease (CKD), a condition typically characterised by sympathetic hyperactivity. A growing body of clinical evidence supports the safety and efficacy of renal denervation in this difficult-to-control population. In addition, preclinical and clinical research indicate potential nephroprotective effects in CKD patients. The current review examines recent research on renal denervation with focus on renal disease and assesses the latest findings and their implications from a nephrologist's perspective.
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Affiliation(s)
- Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-University, Erlangen-Nuremberg, Germany
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14
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Striepe K, Schiffer M, Schmieder R. [Renal denervation : Really an alternative to reducing blood pressure?]. Internist (Berl) 2022; 63:330-340. [PMID: 35029703 DOI: 10.1007/s00108-021-01242-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 10/19/2022]
Abstract
Since the current guidelines were published in 2018, a total of 5 sham-controlled high-quality studies evaluating renal denervation have been conducted and the results were published. These five studies clearly confirmed the efficacy and safety of renal denervation, which correspond to the knowledge of the Clinical Consensus Conference. Thus, an update of the guidelines for the treatment of arterial hypertension regarding the clinical significance of renal denervation is urgently necessary. For this reason, the position paper of the working group of the European Society of Hypertension on the current state of renal denervation was reviewed. An approval of this procedure can soon be expected. In Germany there is a diagnosis-related group (DRG) for the reimbursement of renal denervation, which was suspended due to the erroneous Symplicity 3 study. This DRG should be revived in practice by a structured process of the implementation of renal denervation. It will then be a joint task of treating physicians and specialists in certified centers to identify eligible patients. In the future, antihypertensive treatment will consist of three pillars: lifestyle measures, pharmacotherapy and interventional treatment. These three treatment options should not be regarded as competitive (which is better) but alternative (patient preference) and additive (the aim is blood pressure control). It is the task of the treating physician to provide the patient with the ideal treatment concept. Clearly, renal denervation will not replace antihypertensive pharmacotherapy; however, it can lead to a reduction of the drug burden and increase of patient adherence to medication. It represents an option of modern antihypertensive treatment and will also become increasingly more important in special patient groups.
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Affiliation(s)
- Kristina Striepe
- Medizinische Klinik 4, Nephrologie und Hypertensiologie, Universitätsklinik Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Deutschland
| | - Mario Schiffer
- Medizinische Klinik 4, Nephrologie und Hypertensiologie, Universitätsklinik Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Deutschland
| | - Roland Schmieder
- Medizinische Klinik 4, Nephrologie und Hypertensiologie, Universitätsklinik Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Deutschland.
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15
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Grassi G. The Sympathetic Nervous System in Hypertension: Roadmap Update of a Long Journey. Am J Hypertens 2021; 34:1247-1254. [PMID: 34355740 PMCID: PMC8643601 DOI: 10.1093/ajh/hpab124] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/30/2021] [Accepted: 08/05/2021] [Indexed: 12/26/2022] Open
Abstract
The present paper will provide an update on the role of sympathetic neural factors in the development and progression of essential hypertension by reviewing data collected in the past 10 years. This will be done by discussing the results of the published studies in which sympathetic neural function in essential hypertension and related disease has been investigated via sophisticated and highly sensitive techniques, such as microneurographic recording of sympathetic nerve traffic and regional norepinephrine spillover. First, the relevance of the pathophysiological background of the neurogenic alterations will be discussed. It will be then examined the behavior of the sympathetic neural function in specific clinical phenotypes, such as resistant hypertension, pseudoresistant hypertension, and hypertensive states displaying elevated resting heart values. This will be followed by a discussion of the main results of the meta-analytic studies examining the behavior of sympathetic nerve traffic in essential hypertension, obesity, metabolic syndrome, and chronic renal failure. The sympathetic effects of renal denervation and carotid baroreceptor stimulation as well as the possible involvement of sympathetic neural factors in the determination of the so-called "residual risk" of the treated hypertensive patients will be finally discussed.
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Affiliation(s)
- Guido Grassi
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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16
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Pisano A, Iannone LF, Leo A, Russo E, Coppolino G, Bolignano D. Renal denervation for resistant hypertension. Cochrane Database Syst Rev 2021; 11:CD011499. [PMID: 34806762 PMCID: PMC8607757 DOI: 10.1002/14651858.cd011499.pub3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Resistant hypertension is highly prevalent among the general hypertensive population and the clinical management of this condition remains problematic. Different approaches, including a more intensified antihypertensive therapy, lifestyle modifications or both, have largely failed to improve patients' outcomes and to reduce cardiovascular and renal risk. As renal sympathetic hyperactivity is a major driver of resistant hypertension, in the last decade renal sympathetic ablation (renal denervation) has been proposed as a possible therapeutic alternative to treat this condition. OBJECTIVES We sought to evaluate the short- and long-term effects of renal denervation in individuals with resistant hypertension on clinical end points, including fatal and non-fatal cardiovascular events, all-cause mortality, hospital admissions, quality of life, blood pressure control, left ventricular hypertrophy, cardiovascular and metabolic profile and kidney function, as well as the potential adverse events related to the procedure. SEARCH METHODS For this updated review, the Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to 3 November 2020: Cochrane Hypertension's Specialised Register, CENTRAL (2020, Issue 11), Ovid MEDLINE, and Ovid Embase. The World Health Organization International Clinical Trials Registry Platform (via CENTRAL) and the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov were searched for ongoing trials. We also contacted authors of relevant papers regarding further published and unpublished work. The searches had no language restrictions. SELECTION CRITERIA We considered randomised controlled trials (RCTs) that compared renal denervation to standard therapy or sham procedure to treat resistant hypertension, without language restriction. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed study risk of bias. We summarised treatment effects on available clinical outcomes and adverse events using random-effects meta-analyses. We assessed heterogeneity in estimated treatment effects using Chi² and I² statistics. We calculated summary treatment estimates as a mean difference (MD) or standardised mean difference (SMD) for continuous outcomes, and a risk ratio (RR) for dichotomous outcomes, together with their 95% confidence intervals (CI). Certainty of evidence has been assessed using the GRADE approach. MAIN RESULTS We found 15 eligible studies (1416 participants). In four studies, renal denervation was compared to sham procedure; in the remaining studies, renal denervation was tested against standard or intensified antihypertensive therapy. Most studies had unclear or high risk of bias for allocation concealment and blinding. When compared to control, there was low-certainty evidence that renal denervation had little or no effect on the risk of myocardial infarction (4 studies, 742 participants; RR 1.31, 95% CI 0.45 to 3.84), ischaemic stroke (5 studies, 892 participants; RR 0.98, 95% CI 0.33 to 2.95), unstable angina (3 studies, 270 participants; RR 0.51, 95% CI 0.09 to 2.89) or hospitalisation (3 studies, 743 participants; RR 1.24, 95% CI 0.50 to 3.11). Based on moderate-certainty evidence, renal denervation may reduce 24-hour ambulatory blood pressure monitoring (ABPM) systolic BP (9 studies, 1045 participants; MD -5.29 mmHg, 95% CI -10.46 to -0.13), ABPM diastolic BP (8 studies, 1004 participants; MD -3.75 mmHg, 95% CI -7.10 to -0.39) and office diastolic BP (8 studies, 1049 participants; MD -4.61 mmHg, 95% CI -8.23 to -0.99). Conversely, this procedure had little or no effect on office systolic BP (10 studies, 1090 participants; MD -5.92 mmHg, 95% CI -12.94 to 1.10). Moderate-certainty evidence suggested that renal denervation may not reduce serum creatinine (5 studies, 721 participants, MD 0.03 mg/dL, 95% CI -0.06 to 0.13) and may not increase the estimated glomerular filtration rate (eGFR) or creatinine clearance (6 studies, 822 participants; MD -2.56 mL/min, 95% CI -7.53 to 2.42). AUTHORS' CONCLUSIONS: In patients with resistant hypertension, there is low-certainty evidence that renal denervation does not improve major cardiovascular outomes and renal function. Conversely, moderate-certainty evidence exists that it may improve 24h ABPM and diastolic office-measured BP. Future trials measuring patient-centred instead of surrogate outcomes, with longer follow-up periods, larger sample size and more standardised procedural methods are necessary to clarify the utility of this procedure in this population.
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Affiliation(s)
- Anna Pisano
- Institute of Clinical Physiology, CNR - Italian National Council of Research, Reggio Calabria, Italy
| | | | - Antonio Leo
- Department of Health Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Emilio Russo
- Department of Health Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Giuseppe Coppolino
- Department of Health Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Davide Bolignano
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
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17
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Tsioufis KP, Dimitriadis K. RADIANCE-HTN TRIO: how the saga of renal denervation revisits hypertension therapy. Cardiovasc Res 2021; 117:e141-e143. [PMID: 34562002 DOI: 10.1093/cvr/cvab274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Konstantinos P Tsioufis
- First Cardiology Clinic, Medical School, University of Athens, Hippokration Hospital, 114 Vasilissis Sofias Ave, Athens 11527, Greece
| | - Kyriakos Dimitriadis
- First Cardiology Clinic, Medical School, University of Athens, Hippokration Hospital, 114 Vasilissis Sofias Ave, Athens 11527, Greece
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18
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Hearon CM, Howden EJ, Fu Q, Yoo JK, Dias KA, Roberts-Reeves MA, Samels M, Sarma S, Nesbitt S, Vongpatanasin W, Goldstein DS, Addo T, Levine BD. Evidence of Reduced Efferent Renal Sympathetic Innervation After Chemical Renal Denervation in Humans. Am J Hypertens 2021; 34:744-752. [PMID: 33677553 DOI: 10.1093/ajh/hpab022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/14/2021] [Accepted: 01/18/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Renal denervation (RDN) is effective at lowering blood pressure. However, it is unknown if ablative procedures elicit sympathetic denervation of the kidneys in humans. The aim of this investigation was to assess sympathetic innervation of the renal cortex following perivascular chemical RDN, which may be particularly effective at ablating perivascular efferent and afferent nerves. METHODS Seven hypertensive patients (4F:3M; 50-65 years) completed PET-CT sympathetic neuroimaging of the renal cortex using 11C-methylreboxetine (11C-MRB, norepinephrine transporter ligand) and 6-[18F]-fluorodopamine (18F-FDA; substrate for the cell membrane norepinephrine transporter) before and 8 weeks after chemical RDN (Peregrine System Infusion Catheter, Ablative Solutions; n = 4; 2F:2M) or control renal angiography (n = 3; 2F:1M). Patients completed physiological phenotyping including 24-hour ambulatory blood pressure, hemodynamics, muscle sympathetic nerve activity, and 24-hour urine collection. RESULTS RDN decreased 11C-MRB-derived radioactivity by ~30% (Δ 11C-MRB/chamber: -0.95 a.u. confidence interval (CI): -1.36 to -0.54, P = 0.0002), indicative of efferent RDN. In contrast, 18F-FDA-derived radioactivity increased (Δ 18F-FDA/chamber: 2.72 a.u. CI: 0.73-4.71, P = 0.009), consistent with reduced vesicular turnover. Controls showed no change in either marker. Ambulatory systolic pressure decreased in 3 of 4 patients (-9 mm Hg CI: -27 to 9, P = 0.058), and central systolic pressure decreased in all patients (-23 mm Hg CI: -51 to 5, P = 0.095). CONCLUSIONS These results are the first to show efferent sympathetic denervation of the renal cortex following RDN in humans. Further studies of mechanisms underlying variable blood pressure lowering in the setting of documented RDN may provide insights into inconsistencies in clinical trial outcomes. CLINICAL TRIALS REGISTRATION Trial Number NCT03465917.
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Affiliation(s)
- Christopher M Hearon
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Erin J Howden
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Qi Fu
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jeung-Ki Yoo
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Katrin A Dias
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Monique A Roberts-Reeves
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
| | - Mitchel Samels
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
| | - Satyam Sarma
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Shawna Nesbitt
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Wanpen Vongpatanasin
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - David S Goldstein
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Tayo Addo
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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19
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DeLalio LJ, Stocker SD. Impact of anesthesia and sex on sympathetic efferent and hemodynamic responses to renal chemo- and mechanosensitive stimuli. J Neurophysiol 2021; 126:668-679. [PMID: 34259043 DOI: 10.1152/jn.00277.2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Activation of renal sensory nerves by chemo- and mechanosensitive stimuli produces changes in efferent sympathetic nerve activity (SNA) and arterial blood pressure (ABP). Anesthesia and sex influence autonomic function and cardiovascular hemodynamics, but it is unclear to what extent anesthesia and sex impact SNA and ABP responses to renal sensory stimuli. We measured renal, splanchnic, and lumbar SNA and ABP in male and female Sprague-Dawley rats during contralateral renal infusion of capsaicin and bradykinin or during elevation in renal pelvic pressure. Responses were evaluated with a decerebrate preparation or Inactin, urethane, or isoflurane anesthesia. Intrarenal arterial infusion of capsaicin (0.1-30.0 μM) increased renal SNA, splanchnic SNA, or ABP but decreased lumbar SNA in the Inactin group. Intrarenal arterial infusion of bradykinin (0.1-30.0 μM) increased renal SNA, splanchnic SNA, and ABP but decreased lumbar SNA in the Inactin group. Elevated renal pelvic pressure (0-20 mmHg, 30 s) significantly increased renal SNA and splanchnic SNA but not lumbar SNA in the Inactin group. In marked contrast, SNA and ABP responses to every renal stimulus were severely blunted in the urethane and decerebrate groups and absent in the isoflurane group. In the Inactin group, the magnitude of SNA responses to chemo- and mechanosensory stimuli were not different between male and female rats. Thus, chemo- and mechanosensitive stimuli produce differential changes in renal, splanchnic, and lumbar SNA. Experimentally, future investigations should consider Inactin anesthesia to examine sympathetic and hemodynamic responses to renal sensory stimuli.NEW & NOTEWORTHY The findings highlight the impact of anesthesia, and to a lesser extent sex, on sympathetic efferent and hemodynamic responses to chemosensory and mechanosensory renal stimuli. Sympathetic nerve activity (SNA) and arterial blood pressure (ABP) responses were present in Inactin-anesthetized rats but largely absent in decerebrate, isoflurane, or urethane preparations. Renal chemosensory stimuli differentially changed SNA: renal and splanchnic SNA increased, but lumbar SNA decreased. Future investigations should consider Inactin anesthesia to study SNA and hemodynamic responses to renal sensory nerve activation.
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Affiliation(s)
- Leon J DeLalio
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sean D Stocker
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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20
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Abstract
This ESH Position Paper 2021 with updated proposed recommendations was deemed necessary after the publication of a set of new pivotal sham-controlled randomized clinical trials (RCTs), which provided important information about the efficacy and safety of endovascular device-based renal denervation (RDN) for hypertension treatment. RDN is effective in reducing or interrupting the sympathetic signals to the kidneys and decreasing whole body sympathetic activity. Five independent, fully completed, sham-controlled RCTs provide conclusive evidence that RDN lowers ambulatory and office blood pressure (BP) to a significantly greater extent than sham treatment. BP-lowering efficacy is evident both in patients with and without concomitant antihypertensive medication. The average decrease of 10 mmHg in office BP is estimated to lower the incidence of cardiovascular events by 25-30%, based on meta-analyses of RCTs using pharmacological treatment. Neither peri-procedural, nor short-term or long-term adverse events or safety signals (available up to 3 years) have been observed. Implementing RDN as an innovative third option in the armamentarium of antihypertensive treatment requires a structured process that ensures the appropriate performance of the endovascular RDN procedure and adequate selection of hypertensive patients. The latter should also incorporate patients' perspective and preference that needs to be respected in a shared decision-making process.
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21
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Liang B, Liang Y, Li R, Gu N. Effect of renal denervation on long-term outcomes in patients with resistant hypertension. Cardiovasc Diabetol 2021; 20:117. [PMID: 34090434 PMCID: PMC8180124 DOI: 10.1186/s12933-021-01309-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 05/28/2021] [Indexed: 12/13/2022] Open
Abstract
Increasing studies strongly prove that renal denervation, a minimally invasive surgery, is a promising new non-drug treatment method that can effectively control blood pressure in patients with resistant hypertension, but the evaluation of the long-term blood pressure control effect of renal denervation for resistant hypertension is still lacking. Here, we critically review current long-term follow-up data about the use of renal denervation for RH to comprehensively evaluate the effectiveness of renal denervation for RH, and to provide practical guidance for practitioners who are establishing a renal denervation service. Limited by the current research, many problems need to be solved before renal denervation is applied to RH. In addition, ambulatory blood pressure should be the first choice for the evaluation of blood pressure. Finally, the continuous antihypertensive effect of renal denervation in different renal denervation systems also needs to be strictly compared.
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Affiliation(s)
- Bo Liang
- Nanjing University of Chinese Medicine, Nanjing, China
| | - Yi Liang
- Southwest Medical University, Luzhou, China
| | - Rui Li
- Nanjing University of Chinese Medicine, Nanjing, China
| | - Ning Gu
- Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, China.
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22
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Mahfoud F, Townsend RR, Kandzari DE, Kario K, Schmieder RE, Tsioufis K, Pocock S, David S, Patel K, Rao A, Walton A, Bloom JE, Weber T, Suppan M, Lauder L, Cohen SA, McKenna P, Fahy M, Böhm M, Weber MA. Changes in Plasma Renin Activity After Renal Artery Sympathetic Denervation. J Am Coll Cardiol 2021; 77:2909-2919. [PMID: 33957242 DOI: 10.1016/j.jacc.2021.04.044] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/23/2021] [Accepted: 04/12/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND The renin-angiotensin-aldosterone system plays a key role in blood pressure (BP) regulation and is the target of several antihypertensive medications. Renal denervation (RDN) is thought to interrupt the sympathetic-mediated neurohormonal pathway as part of its mechanism of action to reduce BP. OBJECTIVES The purpose of this study was to evaluate plasma renin activity (PRA) and aldosterone before and after RDN and to assess whether these baseline neuroendocrine markers predict response to RDN. METHODS Analyses were conducted in patients with confirmed absence of antihypertensive medication. Aldosterone and PRA levels were compared at baseline and 3 months post-procedure for RDN and sham control groups. Patients in the SPYRAL HTN-OFF MED Pivotal trial were separated into 2 groups, those with baseline PRA ≥0.65 ng/ml/h (n = 110) versus <0.65 ng/ml/h (n = 116). Follow-up treatment differences between RDN and sham control groups were adjusted for baseline values using multivariable linear regression models. RESULTS Baseline PRA was similar between RDN and control groups (1.0 ± 1.1 ng/ml/h vs. 1.1 ± 1.1 ng/ml/h; p = 0.37). Change in PRA at 3 months from baseline was significantly greater for RDN compared with control subjects (-0.2 ± 1.0 ng/ml/h; p = 0.019 vs. 0.1 ± 0.9 ng/ml/h; p = 0.14), p = 0.001 for RDN versus control subjects, and similar differences were seen for aldosterone: RDN compared with control subjects (-1.2 ± 6.4 ng/dl; p = 0.04 vs. 0.4 ± 5.4 ng/dl; p = 0.40), p = 0.011. Treatment differences at 3 months in 24-h and office systolic blood pressure (SBP) for RDN versus control patients were significantly greater for patients with baseline PRA ≥0.65 ng/ml/h versus <0.65 ng/ml/h, despite similar baseline BP. Differences in office SBP changes according to baseline PRA were also observed earlier at 2 weeks post-RDN. CONCLUSIONS Plasma renin activity and aldosterone levels for RDN patients were significantly reduced at 3 months when compared with baseline as well as when compared with sham control. Higher baseline PRA levels were associated with a significantly greater reduction in office and 24-h SBP. (SPYRAL PIVOTAL - SPYRAL HTN-OFF MED Study; NCT02439749).
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Affiliation(s)
- Felix Mahfoud
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany.
| | - Raymond R Townsend
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David E Kandzari
- Department of Interventional Cardiology, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Kazuomi Kario
- Department of Cardiovascular Medicine and Department of Sleep and Circadian Cardiology, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Roland E Schmieder
- Department of Nephrology and Hypertension, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Konstantinos Tsioufis
- Department of Cardiology, University of Athens, Hippocratio Hospital, Athens, Greece
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Shukri David
- Department of Cardiology, Providence Hospital, Southfield, Michigan, USA
| | - Kiritkumar Patel
- Department of Cardiology, Saint Joseph Mercy Oakland, Bloomfield Hills, Michigan, USA
| | - Anjani Rao
- Department of Cardiology, Saint Joseph Mercy Oakland, Bloomfield Hills, Michigan, USA
| | - Antony Walton
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jason E Bloom
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Thomas Weber
- Department of Cardiology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Markus Suppan
- Department of Cardiology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Lucas Lauder
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Sidney A Cohen
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Coronary and Renal Denervation Division, Medtronic PLC, Santa Rosa, California, USA
| | - Pamela McKenna
- Coronary and Renal Denervation Division, Medtronic PLC, Santa Rosa, California, USA
| | - Martin Fahy
- Coronary and Renal Denervation Division, Medtronic PLC, Santa Rosa, California, USA
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Michael A Weber
- Department of Medicine, SUNY Downstate College of Medicine, Brooklyn, New York, USA
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Seravalle G, Quarti-Trevano F, Vanoli J, Lovati C, Grassi G. Autonomic cardiovascular alterations as therapeutic targets in chronic kidney disease. Clin Auton Res 2021; 31:491-498. [PMID: 33606138 PMCID: PMC8292281 DOI: 10.1007/s10286-021-00786-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 02/05/2021] [Indexed: 12/25/2022]
Abstract
Purpose The present paper will review the impact of different therapeutic interventions on the autonomic dysfunction characterizing chronic renal failure. Methods We reviewed the results of the studies carried out in the last few years examining the effects of standard pharmacologic treatment, hemodialysis, kidney transplantation, renal nerve ablation and carotid baroreceptor stimulation on parasympathetic and sympathetic control of the cardiovascular system in patients with renal failure. Results Drugs acting on the renin–angiotensin system as well as central sympatholytic agents have been documented to improve autonomic cardiovascular control. This has also been shown for hemodialysis, although with more heterogeneous results related to the type of dialytic procedure adopted. Kidney transplantation, in contrast, particularly when performed together with the surgical removal of the native diseased kidneys, has been shown to cause profound sympathoinhibitory effects. Finally, a small amount of promising data are available on the potential favorable autonomic effects (particularly the sympathetic ones) of renal nerve ablation and carotid baroreceptor stimulation in chronic kidney disease. Conclusions Further studies are needed to clarify several aspects of the autonomic responses to therapeutic interventions in chronic renal disease. These include (1) the potential to normalize sympathetic activity in uremic patients by the various therapeutic approaches and (2) the definition of the degree of sympathetic deactivation to be achieved during treatment.
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Affiliation(s)
- Gino Seravalle
- Clinica Medica, Department of Medicine and Surgery, University Milano-Bicocca, Milan, Italy
| | - Fosca Quarti-Trevano
- Clinica Medica, Department of Medicine and Surgery, University Milano-Bicocca, Milan, Italy
| | - Jennifer Vanoli
- Clinica Medica, Department of Medicine and Surgery, University Milano-Bicocca, Milan, Italy
| | - Chiara Lovati
- Clinica Medica, Department of Medicine and Surgery, University Milano-Bicocca, Milan, Italy
| | - Guido Grassi
- Clinica Medica, Department of Medicine and Surgery, University Milano-Bicocca, Milan, Italy. .,Clinica Medica, University Milano-Bicocca, Via Pergolesi 33, 20052, Monza, Italy.
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Quarti-Trevano F, Seravalle G, Dell'Oro R, Mancia G, Grassi G. Autonomic Cardiovascular Alterations in Chronic Kidney Disease: Effects of Dialysis, Kidney Transplantation, and Renal Denervation. Curr Hypertens Rep 2021; 23:10. [PMID: 33582896 PMCID: PMC7882573 DOI: 10.1007/s11906-021-01129-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW To review the results of studies of the effects of dialysis and kidney transplantation on the autonomic nervous system alterations that occur in chronic kidney disease. RECENT FINDINGS Vagal control of the heart mediated by arterial baroreceptors is altered early in the course of the renal disease. Sympathetic activation occurs, with increases in resting heart rate, venous plasma norepinephrine levels, muscle sympathetic nerve traffic, and other indirect indices of adrenergic drive. The magnitude of the changes reflects the clinical severity of the kidney disease. Both the sympathetic and parasympathetic alterations have a reflex origin, depending on the impairment in baroreflex and cardiopulmonary reflex control of the cardiovascular system. These alterations are partially reversed during acute hemodialysis, but the responses are variable depending on the specific type of dialytic treatment that is employed. Renal transplantation improves reflex cardiovascular control, resulting in sympathoinhibition following renal transplantation if the native kidneys are removed. Sympathoinhibitory effects have been also reported in renal failure patients after bilateral renal denervation. Assessment of autonomic nervous system responses to dialysis and renal transplantation provides information of clinical interest, given the evidence that autonomic alterations are involved in the development and progression of cardiovascular complications, as well as in the prognosis of chronic kidney disease.
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Affiliation(s)
- Fosca Quarti-Trevano
- Clinica Medica, Department of Medicine and Surgery, University Milano-Bicocca, Via Pergolesi 33, 20052, Monza, Italy
| | - Gino Seravalle
- Clinica Medica, Department of Medicine and Surgery, University Milano-Bicocca, Via Pergolesi 33, 20052, Monza, Italy
| | - Raffaella Dell'Oro
- Clinica Medica, Department of Medicine and Surgery, University Milano-Bicocca, Via Pergolesi 33, 20052, Monza, Italy
| | - Giuseppe Mancia
- Policlinico di Monza and University Milano-Bicocca, Milan, Italy
| | - Guido Grassi
- Clinica Medica, Department of Medicine and Surgery, University Milano-Bicocca, Via Pergolesi 33, 20052, Monza, Italy.
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DeLalio LJ, Stocker SD. Impact of anesthesia, sex, and circadian cycle on renal afferent nerve sensitivity. Am J Physiol Heart Circ Physiol 2021; 320:H117-H132. [PMID: 33216622 PMCID: PMC7847066 DOI: 10.1152/ajpheart.00675.2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/17/2020] [Accepted: 11/17/2020] [Indexed: 01/09/2023]
Abstract
Elevated renal afferent nerve (ARNA) activity or dysfunctional reno-renal reflexes via altered ARNA sensitivity contribute to hypertension and chronic kidney disease. These nerves contain mechano- and chemosensitive fibers that respond to ischemia, changes in intrarenal pressures, and chemokines. Most studies have utilized various anesthetized preparations and exclusively male animals to characterize ARNA responses. Therefore, this study assessed the impact of anesthesia, sex, and circadian period on ARNA responses and sensitivity. Multifiber ARNA recordings were performed in male and female Sprague-Dawley rats (250-400 g) and compared across decerebrate versus Inactin, isoflurane, and urethane anesthesia groups. Intrarenal artery infusion of capsaicin (0.1-50.0 μM, 0.05 mL) produced concentration-dependent increases in ARNA; however, the ARNA sensitivity was significantly greater in decerebrate versus Inactin, isoflurane, and urethane groups. Increases in renal pelvic pressure (0-30 mmHg, 30 s) produced pressure-dependent increases in ARNA; however, ARNA sensitivity was again greater in decerebrate and Inactin groups versus isoflurane and urethane. Acute renal artery occlusion (30 s) increased ARNA, but responses did not differ across groups. Analysis of ARNA responses to increased pelvic pressure between male and female rats revealed significant sex differences only in isoflurane and urethane groups. ARNA responses to intrarenal capsaicin infusion were significantly blunted at nighttime versus daytime; however, ARNA responses to increased pelvic pressure or renal artery occlusion were not different between daytime and nighttime. These results demonstrate that ARNA sensitivity is greatest in decerebrate and Inactin-anesthetized groups but was not consistently influenced by sex.NEW & NOTEWORTHY We determined the impact of anesthesia, sex, and circadian cycle on renal afferent nerve (ARNA) sensitivity to chemical and mechanical stimuli. ARNA sensitivity to renal capsaicin infusion was greatest in decerebrate > Inactin > urethane or isoflurane groups. Elevated renal pelvic pressure significantly increased ARNA; decerebrate and Inactin groups exhibited the greatest ARNA sensitivity. Sex differences in renal afferent responses were not consistently observed. Circadian cycle altered chemosensory but not mechanosensory responses.
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Affiliation(s)
- Leon J DeLalio
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sean D Stocker
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Schmieder RE. Renal denervation: where do we stand and what is the relevance to the nephrologist? Nephrol Dial Transplant 2020; 37:638-644. [DOI: 10.1093/ndt/gfaa237] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Indexed: 01/21/2023] Open
Abstract
Abstract
Catheter-based renal denervation to reduce high blood pressure (BP) has received well-deserved attention after a recent series of sham-controlled trials reported significant antihypertensive efficacy and very favourable tolerability and safety of the intervention. This emerging treatment option is of high relevance to nephrologists. Patients with chronic kidney disease (CKD) are at elevated risk of cardiovascular adverse events and often present with hypertension, which is very difficult to control with medication. Renal denervation promises a new tool to reduce BP and to prevent loss of renal function in this population. The current review considers the role of the kidney and neurohormonal activation in the development of hypertension and the rationale for renal denervation. The current state of the evidence for the effectiveness and tolerability of the procedure is considered from the nephrologists’ perspective, with a focus on the potential future role of renal denervation in the management of CKD patients with hypertension.
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Affiliation(s)
- Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-University, Erlangen-Nuremberg, Germany
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Seravalle G, Dell’Oro R, Quarti-Trevano F, Spaziani D, Bertoli S, Airoldi F, Mancia G, Grassi G. Sympathetic Overactivation in Patients With Essential Hypertension and Hepatic Iron Overload. Hypertension 2020; 76:1444-1450. [DOI: 10.1161/hypertensionaha.120.15511] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Iron overload has been recently shown to be associated with a hyperadrenergic state in genetic hemochromatosis. Whether this is also the case in essential hypertension, characterized by sympathetic activation and frequently by body iron overload, is unknown. In 17 healthy normotensive controls (age 52.3±3.2 years, mean±SE), in 21 age-matched patients with hypertension with iron overload (HT+), defined by serum ferritin levels, and in 28 hypertensives without this condition, we measured efferent postganglionic muscle sympathetic nerve traffic (microneurography), heart rate and blood pressure variability (power spectral analysis), serum ferritin, and metabolic variables. Muscle sympathetic nerve traffic was significantly (P<0.02 at least) greater in HT+ than in patients with hypertension without iron overload and normotensive subjects both when expressed as bursts incidence over time (41.8±1.4 versus 31.5±1.4 and 23.6±0.9 bursts/min) and as bursts corrected for heart rate (55.3±1.8 versus 42.3±1.2 and 31.7±1.2 bursts/100 heartbeats). In HT+, low-frequency systolic blood pressure variability was significantly reduced. In HT+, but not in the other 2 groups, muscle sympathetic nerve traffic was significantly related to serum ferritin (r=0.51,P<0.03), transferrin saturation (r=0.47,P<0.03), and hepatic iron load (r=0.76,P<0.0001, magnetic resonance imaging), as well as to homeostatic model assessment index values (r=0.46,P<0.05). These data provide the first evidence that in HT+ elevated serum ferritin is associated with a hyperadrenergic state of greater magnitude than the one seen in patients with hypertension without iron overload. They also show that the potentiation of the sympathetic activation detected in HT+ is related to elevated serum ferritin and to the associated metabolic alterations, possibly participating in the increased cardiovascular risk characterizing iron overload.
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Affiliation(s)
- Gino Seravalle
- From the Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Italy (G.S., R.D., F.Q.-T., G.G.)
| | - Raffaella Dell’Oro
- From the Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Italy (G.S., R.D., F.Q.-T., G.G.)
| | - Fosca Quarti-Trevano
- From the Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Italy (G.S., R.D., F.Q.-T., G.G.)
| | | | - Silvio Bertoli
- Istituto a Carattere Scientifico Multimedica, Sesto San Giovanni, Milan, Italy (S.B., F.A.)
| | - Flavio Airoldi
- Istituto a Carattere Scientifico Multimedica, Sesto San Giovanni, Milan, Italy (S.B., F.A.)
| | - Giuseppe Mancia
- University Milano-Bicocca and Policlinico di Monza, Italy (G.M.)
| | - Guido Grassi
- From the Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Italy (G.S., R.D., F.Q.-T., G.G.)
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Renal denervation in patients with end-stage renal disease and resistant hypertension on long-term haemodialysis. J Hypertens 2020; 38:936-942. [DOI: 10.1097/hjh.0000000000002358] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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DeLalio LJ, Sved AF, Stocker SD. Sympathetic Nervous System Contributions to Hypertension: Updates and Therapeutic Relevance. Can J Cardiol 2020; 36:712-720. [PMID: 32389344 DOI: 10.1016/j.cjca.2020.03.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/02/2020] [Accepted: 03/03/2020] [Indexed: 12/15/2022] Open
Abstract
The sympathetic nervous system plays a pivotal role in the long-term regulation of arterial blood pressure through the ability of the central nervous system to integrate neurohumoral signals and differentially regulate sympathetic neural input to specific end organs. Part 1 of this review will discuss neural mechanisms of salt-sensitive hypertension, obesity-induced hypertension, and the ability of prior experiences to sensitize autonomic networks. Part 2 of this review focuses on new therapeutic advances to treat resistant hypertension including renal denervation and carotid baroactivation. Both advances lower arterial blood pressure by reducing sympathetic outflow. We discuss potential mechanisms and areas of future investigation to target the sympathetic nervous system.
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Affiliation(s)
- Leon J DeLalio
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alan F Sved
- Department of Neuroscience, University of Pittsburgh, Pennsylvania, USA
| | - Sean D Stocker
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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Bosch A, Schmid A, Ott C, Kannenkeril D, Karg MV, Ditting T, Veelken R, Uder M, Schmieder RE. Copeptin Levels in Patients With Treatment-Resistant Hypertension Before and 6 Months After Renal Denervation. Am J Hypertens 2020; 33:182-189. [PMID: 31555795 DOI: 10.1093/ajh/hpz155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 07/14/2019] [Accepted: 09/17/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Copeptin, the C-terminal peptide of provasopressin, is released from the neurohypophysis and reflects the activity of the hormone arginine vasopressin in patients with hypertension. Elevated copeptin levels are associated with increased cardiovascular and all-cause mortality. The aim of this study is to compare copeptin levels in patients with treatment-resistant hypertension (TRH) before and 6 months after renal denervation (RDN). METHODS Copeptin was measured in 34 patients with TRH and 30 patients with primary hypertension stage 1 or 2 (HT). In addition, copeptin levels were measured in patients with TRH at 6-month follow-up visit after RDN. RDN was performed by an experienced interventionalist applying at least 4 ablations longitudinally and rotationally within the lengths of each renal artery to cover a full 4-quadrant ablation. RESULTS In patients with TRH 24-hour ambulatory blood pressure (BP) decreased from 154 ± 15/87 ± 12 mm Hg to 146 ± 13/83 ± 7.9 mm Hg after RDN (systolic: P = 0.001, diastolic: P = 0.034). There was no significant change in copeptin levels in these 34 patients with TRH before vs. 6 months after RDN (median 8.4 [interquartile range 3.6-14] vs. 8.5 [4.5-13] pmol/l, P = 0.334). Patients with TRH had higher copeptin levels (P = 0.024) than patients with HT (24-hour ambulatory BP: 142 ± 11/91 ± 8.3 mm Hg, copeptin: 4.2 [2.8-6.3] pmol/l). CONCLUSION Patients with TRH showed 2-fold higher copeptin levels than patients with HT. RDN did not lead to any change of copeptin levels in patients with TRH 6 months after procedure despite significant fall in BP. CLINICAL TRIAL REGISTRATION NCT01318395, NCT01687725.
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Affiliation(s)
- Agnes Bosch
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Axel Schmid
- Department of Radiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Christian Ott
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
- Department of Nephrology and Hypertension, Paracelsus Medical University, Nürnberg, Germany
| | - Dennis Kannenkeril
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Marina V Karg
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Tilmann Ditting
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
- Department of Nephrology and Hypertension, Paracelsus Medical University, Nürnberg, Germany
| | - Roland Veelken
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
- Department of Nephrology and Hypertension, Paracelsus Medical University, Nürnberg, Germany
| | - Michael Uder
- Department of Radiology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
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Abstract
Despite availability of effective drugs for hypertension therapy, significant numbers of hypertensive patients fail to achieve recommended blood pressure levels on ≥3 antihypertensive drugs of different classes. These individuals have a high prevalence of adverse cardiovascular events and are defined as having resistant hypertension (RHT) although nonadherence to prescribed antihypertensive medications is common in patients with apparent RHT. Furthermore, apparent and true RHT often display increased sympathetic activity. Based on these findings, technology was developed to treat RHT by suppressing sympathetic activity with electrical stimulation of the carotid baroreflex and catheter-based renal denervation (RDN). Over the last 15 years, experimental and clinical studies have provided better understanding of the physiological mechanisms that account for blood pressure lowering with baroreflex activation and RDN and, in so doing, have provided insight into which patients in this heterogeneous hypertensive population are most likely to respond favorably to these device-based therapies. Experimental studies have also played a role in modifying device technology after early clinical trials failed to meet key endpoints for safety and efficacy. At the same time, these studies have exposed potential differences between baroreflex activation and RDN and common challenges that will likely impact antihypertensive treatment and clinical outcomes in patients with RHT. In this review, we emphasize physiological studies that provide mechanistic insights into blood pressure lowering with baroreflex activation and RDN in the context of progression of clinical studies, which are now at a critical point in determining their fate in RHT management.
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Affiliation(s)
- Thomas E Lohmeier
- From the Department of Physiology and Biophysics (T.E.L., J.E.H.), University of Mississippi Medical Center, Jackson
| | - John E Hall
- From the Department of Physiology and Biophysics (T.E.L., J.E.H.), University of Mississippi Medical Center, Jackson.,Mississippi Center for Obesity Research (J.E.H.), University of Mississippi Medical Center, Jackson
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Effects of renal denervation on 24-h heart rate and heart rate variability in resistant hypertension. Clin Res Cardiol 2019; 109:581-588. [DOI: 10.1007/s00392-019-01543-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 08/23/2019] [Indexed: 12/12/2022]
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Ong J, Kinsman BJ, Sved AF, Rush BM, Tan RJ, Carattino MD, Stocker SD. Renal sensory nerves increase sympathetic nerve activity and blood pressure in 2-kidney 1-clip hypertensive mice. J Neurophysiol 2019; 122:358-367. [PMID: 31091159 DOI: 10.1152/jn.00173.2019] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Renal denervation lowers arterial blood pressure (ABP) in multiple clinical trials and some experimental models of hypertension. These antihypertensive effects have been attributed to the removal of renal afferent nerves. The purpose of the present study was to define the function, anatomy, and contribution of mouse renal sensory neurons to a renal nerve-dependent model of hypertension. First, electrical stimulation of mouse renal afferent nerves produced frequency-dependent increases in ABP that were eliminated by ganglionic blockade. Stimulus-triggered averaging revealed renal afferent stimulation significantly increased splanchnic, renal, and lumbar sympathetic nerve activity (SNA). Second, kidney injection of wheat germ agglutinin into male C57Bl6 mice (12-14 wk; Jackson Laboratories) produced ipsilateral labeling in the T11-L2 dorsal root ganglia. Next, 2-kidney 1-clip (2K1C) hypertension was produced in male C57Bl6 mice (12-14 wk; Jackson Laboratories) by placement of a 0.5-mm length of polytetrafluoroethylene tubing around the left renal artery. 2K1C mice displayed an elevated ABP measured via telemetry and a greater fall in mean ABP to ganglionic blockade at day 14 or 21 vs. day 0. Renal afferent discharge was significantly higher in 2K1C-clipped vs. 2K1C-unclipped or sham kidneys. In addition, 2K1C-clipped vs. 2K1C-unclipped or sham kidneys had lower renal mass and higher mRNA levels of several proinflammatory cytokines. Finally, both ipsilateral renal denervation (10% phenol) or selective denervation of renal afferent nerves (periaxonal application of 33 mM capsaicin) at time of clipping resulted in lower ABP of 2K1C mice at day 14 or 21. These findings suggest mouse renal sensory neurons are activated to increase SNA and ABP in 2K1C hypertension. NEW & NOTEWORTHY This study documents the function, anatomy, and contribution of mouse renal sensory nerves to neurogenic hypertension produced by renal stenosis. Activation of renal afferents increased sympathetic nerve activity and blood pressure. Renal afferent activity was elevated in hypertensive mice, and renal afferent denervation lowered blood pressure. Clinically, patients with renal stenosis have been excluded from clinical trials for renal denervation, but this study highlights the potential therapeutic efficacy to target renal nerves in these patients.
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Affiliation(s)
- Jason Ong
- Division of Renal-Electrolyte, Department of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania.,Department of Neuroscience, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Brian J Kinsman
- Division of Renal-Electrolyte, Department of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Alan F Sved
- Department of Neuroscience, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Brittney M Rush
- Division of Renal-Electrolyte, Department of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Roderick J Tan
- Division of Renal-Electrolyte, Department of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Marcelo D Carattino
- Division of Renal-Electrolyte, Department of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Sean D Stocker
- Division of Renal-Electrolyte, Department of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
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Phase II randomized sham-controlled study of renal denervation for individuals with uncontrolled hypertension - WAVE IV. J Hypertens 2019; 36:680-689. [PMID: 29035942 DOI: 10.1097/hjh.0000000000001584] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The aim of this double-blind, randomized, sham-controlled study was to verify the blood pressure (BP)-lowering efficacy of externally delivered focused ultrasound for renal denervation (RDN). BACKGROUND Nonrandomized, first proof-of-concept study and experimental evidence suggested that noninvasive techniques of RDN emerged as an alternative approach of RDN to invasive technologies. METHODS WAVE IV, an international, randomized (1 : 1) sham-controlled, double-blind prospective clinical study, was prematurely stopped. Patients were enrolled if office BP was at least 160 mmHg and 24-h ambulatory BP was at least 135 mmHg, while taking three or more antihypertensive medications. The treatment consisted of bilateral RDN using therapeutic levels of ultrasound energy and the sham consisted of bilateral application of diagnostic levels of ultrasound energy. RESULTS In the 81 treated patients neither changes in office BP at 12 and 24 weeks, nor changes in 24-h ambulatory BP at 24-week follow-up visit differed between the two groups significantly. Of note, no safety signal was observed. Adherence analysis disclosed full adherence in 77% at baseline and 82% at 6 months' follow-up visit. Post hoc analysis revealed that stricter criteria for stabilization of BP at baseline were associated with a numerically greater change in 24-h ambulatory BP in the RDN group than in the sham group. CONCLUSION Our data did not prove that antihypertensive efficacy of the externally delivered focused ultrasound for RDN was greater than the sham effect. Stabilization of BP at baseline was identified as an important determinant of BP changes.
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Blood pressure response to renal denervation is correlated with baseline blood pressure variability: a patient-level meta-analysis. J Hypertens 2019; 36:221-229. [PMID: 29045339 DOI: 10.1097/hjh.0000000000001582] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Sympathetic tone is one of the main determinants of blood pressure (BP) variability and treatment-resistant hypertension. The aim of our study was to assess changes in BP variability after renal denervation (RDN). In addition, on an exploratory basis, we investigated whether baseline BP variability predicted the BP changes after RDN. METHODS We analyzed 24-h BP recordings obtained at baseline and 6 months after RDN in 167 treatment-resistant hypertension patients (40% women; age, 56.7 years; mean 24-h BP, 152/90 mmHg) recruited at 11 expert centers. BP variability was assessed by weighted SD [SD over time weighted for the time interval between consecutive readings (SDiw)], average real variability (ARV), coefficient of variation, and variability independent of the mean (VIM). RESULTS Mean office and 24-h BP fell by 15.4/6.6 and 5.5/3.7 mmHg, respectively (P < 0.001). In multivariable-adjusted analyses, systolic/diastolic SDiw and VIM for 24-h SBP/DBP decreased by 1.18/0.63 mmHg (P ≤ 0.01) and 0.86/0.42 mmHg (P ≤ 0.05), respectively, whereas no significant changes in ARV or coefficient of variation occurred. Furthermore, baseline SDiw (P = 0.0006), ARV (P = 0.01), and VIM (P = 0.04) predicted the decrease in 24-h DBP but not 24-h SBP after RDN. CONCLUSION RDN was associated with a decrease in BP variability independent of the BP level, suggesting that responders may derive benefits from the reduction in BP variability as well. Furthermore, baseline DBP variability estimates significantly correlated with mean DBP decrease after RDN. If confirmed in younger patients with less arterial damage, in the absence of the confounding effect of drugs and drug adherence, baseline BP variability may prove a good predictor of BP response to RDN.
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Völz S, Lundblad LC, Andersson B, Multing J, Rundqvist B, Elam M. Unaltered neurocardiovascular reactions to mental stress after renal sympathetic denervation. Clin Exp Hypertens 2019; 42:160-166. [PMID: 30870039 DOI: 10.1080/10641963.2019.1590387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: The impact of renal denervation (RDN) on muscle sympathetic nerve activity (MSNA) at rest remains controversial. Mental stress (MS) induces transient changes in sympathetic nerve activity, heart rate (HR) and blood pressure (BP). It is not known whether RDN modifies these changes.Purpose: The main objective was to assess the effect of RDN on MSNA and BP alterations during MS.Methods: In 14 patients (11 included in analysis) with resistant hypertension multi-unit MSNA, BP (Finometer ®) and HR were assessed at rest and during forced arithmetics at baseline and 6 months after RDN.Results: Systolic office BP decreased significantly 6 months after RDN (185 ± 29 vs.175 ± 33 mmHG; p = 0.04). No significant changes in MSNA at rest (68 ± 5 vs 73 ± 5 bursts/100hb; p = 0.43) were noted and no significant stress-induced change in group averaged sympathetic activity was found pre- (101 ± 24%; p = 0.9) or post-intervention (108 ± 26%; p = 0.37). Stress was associated with significant increases in mean arterial BP (p < 0.01) and HR (p < 0.01) at baseline, reactions which remained unaltered after intervention. We did not note any correlation between sympathetic nerve activity and BP changes after RDN.Conclusion: Thus, in our group of resistant hypertensives we find no support for the hypothesis that the BP-lowering effect of RDN depends on altered neurovascular responses to stress.
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Affiliation(s)
- Sebastian Völz
- Department of Cardiology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Linda C Lundblad
- Institute of Neuroscience and Physiology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Bert Andersson
- Department of Cardiology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Jonas Multing
- Department of Cardiology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Bengt Rundqvist
- Department of Cardiology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Mikael Elam
- Institute of Neuroscience and Physiology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
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Mahfoud F, Bakris G, Bhatt DL, Esler M, Ewen S, Fahy M, Kandzari D, Kario K, Mancia G, Weber M, Böhm M. Reduced blood pressure-lowering effect of catheter-based renal denervation in patients with isolated systolic hypertension: data from SYMPLICITY HTN-3 and the Global SYMPLICITY Registry. Eur Heart J 2018; 38:93-100. [PMID: 28158510 PMCID: PMC5381589 DOI: 10.1093/eurheartj/ehw325] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 04/27/2016] [Accepted: 06/29/2016] [Indexed: 12/26/2022] Open
Abstract
Aims Catheter-based renal artery denervation (RDN) has been shown to lower blood pressure (BP) in certain patients with uncontrolled hypertension. Isolated systolic hypertension (ISH) (systolic BP [SBP] ≥140 mmHg and diastolic BP <90 mmHg), characterized by increased vascular stiffness, is the predominant hypertensive phenotype in elderly patients. This study compared baseline characteristics and SBP change at 6 months between patients with ISH and combined systolic–diastolic hypertension (CH). Methods and results This study pooled data from 1103 patients from SYMPLICITY HTN-3 and the Global SYMPLICITY Registry. A total of 429 patients had ISH, and 674 had CH. Patients with ISH were significantly older than those with CH (66 vs. 55 years), had more type 2 diabetes mellitus (52.9 vs. 34.6%), and a lower estimated glomerular filtration rate (71.8 vs. 78.6 mL/min/1.73 m2); all P < 0.001. At 6 months, the SBP drop for CH patients was −18.7 ± 23.7 mmHg compared with a reduction of −10.9 ± 21.7 mmHg for ISH patients −7.8 mmHg, 95% confidence interval, CI, −10.5, −5.1, P < 0.001). The change in 24-h SBP at 6 months was −8.8 ± 16.2 mmHg in patients with CH vs. −5.8 ± 15.4 mmHg in ISH (−3.0 mmHg, 95% CI −5.4, −0.6, P = 0.015). Presence of ISH at baseline but not age was associated with less pronounced BP changes following the procedure. The strongest predictor of office SBP reduction at 6 months was CH, followed by aldosterone antagonist use and non-use of vasodilators. Conclusion The reduction in BP among patients with ISH following RDN was less pronounced than the reduction in patients with CH. Clinical.Trials.gov identifiers NCT01534299 and NCT01418261.
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Affiliation(s)
- Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Saarland University Hospital, Kirrberger Str., Geb. 40, Homburg/Saar 66421, Germany
- Corresponding author. Tel: +49 6841 16 15911, Fax: +49 6841 16 15910,
| | | | - Deepak L. Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Murray Esler
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Saarland University Hospital, Kirrberger Str., Geb. 40, Homburg/Saar 66421, Germany
| | | | | | - Kazuomi Kario
- Jichi Medical University School of Medicine, Tochigi, Japan
| | - Giuseppe Mancia
- University of Milano-Bicocca and Istituto Auxologico Italiano, Milan, Italy
| | | | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Saarland University Hospital, Kirrberger Str., Geb. 40, Homburg/Saar 66421, Germany
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Morganti A, Mancia G. Resistant hypertension: Renal denervation or intensified medical treatment? Eur J Intern Med 2018; 50:6-11. [PMID: 29287767 DOI: 10.1016/j.ejim.2017.12.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 12/22/2017] [Indexed: 12/27/2022]
Abstract
Resistant hypertension (RH) can be diagnosed if blood pressure (BP) is not controlled with the combination of three antihypertensive drugs, including a diuretic, all at effective doses. Patients affected by this condition exhibit a marked increase in the risk of cardiovascular and renal morbid and fatal events. They also exhibit an increased activity of the sympathetic nervous system which is likely to importantly contribute at the renal and other vascular levels to the hypertensive state. Almost 10years ago renal denervation (RDN) by radiofrequency thermal energy delivery to the walls of the renal arteries was proposed for the treatment of RH. Several uncontrolled studies initially reported that this procedure substantially reduced the elevated BP values but this conclusion has not been supported by a recent randomized control trial, which has almost marginalized this therapeutic approach. A revival, however, is under way because of recent positive findings and technical improvement that hold promise to make renal denervation more complete. The antihypertensive efficacy and overall validity of RDN will have to be tested against drug treatment of RH. Several studies indicate that an excess of aldosterone production contributes to RH and recent evidence documents indisputably that anti-aldosterone agents such as spironolactone can effectively control BP in many RH patients, although with some side effects that require close patients' monitoring. At present, it is advisable to treat RH with the addition of an anti-aldosterone agent. If BP control is not achieved or serious side effects become manifest RDN may then be considered.
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Affiliation(s)
- Alberto Morganti
- Centro Fisiologia Clinica e Ipertensione, Ospedale Policlinico, Università Milano, Milan, Italy
| | - Giuseppe Mancia
- Università degli Studi di Milano-Bicocca, Milano, Italy; Policlinico di Monza, Istituto di Ricovero e Cura ad Alta Specializzazione, Monza, Italy.
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Seravalle G, D'Arrigo G, Tripepi G, Mallamaci F, Brambilla G, Mancia G, Grassi G, Zoccali C. Sympathetic nerve traffic and blood pressure changes after bilateral renal denervation in resistant hypertension: a time-integrated analysis. Nephrol Dial Transplant 2018; 32:1351-1356. [PMID: 28810724 DOI: 10.1093/ndt/gfx200] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Indexed: 11/13/2022] Open
Abstract
Background Renal denervation reduces blood pressure (BP) and sympathetic drive in experimental animal models, but the effect of this intervention on sympathetic activity in patients with treatment-resistant hypertension is still unclear. Methods In an incident series of 29 patients with treatment-resistant hypertension, we performed serial measurements (n = 123) of muscle sympathetic nerve activity (MSNA, microneurography) and standardized BP measurements. Data were analysed by mixed linear modelling (MLM) and by regression analysis of time-integrated changes of both MSNA and synchronous, standardized (in-lab) BP measurements. Results Bilateral renal denervation was accompanied by a marked reduction in MSNA (P = 0.01 by MLM), which was parallelled by a reduction in systolic (from 175 ± 14 to 156 ± 16 mmHg) and, to a lesser extent, in diastolic (from 96 ± 12 to 87 ± 6 mmHg) BP over time. Neither systolic nor diastolic BP associated to a significant extent with corrected MSNA (MSNAC) in the MLM analysis (systolic BP versus MSNAC: β = -0.08, P = 0.08; diastolic BP versus MSNAC: β = -0.007, P = 0.75). However, the study of time-integrated changes in MSNA and BP showed a robust association between proportional changes in MSNA over time and simultaneous changes in systolic and diastolic BP (β = 0.61, P < 0.001 and β = 0.37 P < 0.05). Conclusions Time-integrated changes in MSNAC and BP after bilateral renal denervation document a close link between the sympathetic activity and BP responses to this procedure. These findings further strengthen the relevance of the sympathetic nervous system both in the pathophysiology of resistant hypertension and in the BP-lowering effect of the procedure.
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Affiliation(s)
- Gino Seravalle
- Clinica Medica, Department of Medicine and Surgery, Università Milano-Bicocca, Milan, Italy
| | - Graziella D'Arrigo
- CNR-IFC, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Giovanni Tripepi
- CNR-IFC, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Gianmaria Brambilla
- Clinica Medica, Department of Medicine and Surgery, Università Milano-Bicocca, Milan, Italy
| | - Giuseppe Mancia
- Clinica Medica, Department of Medicine and Surgery, Università Milano-Bicocca, Milan, Italy
| | - Guido Grassi
- Clinica Medica, Department of Medicine and Surgery, Università Milano-Bicocca, Milan, Italy.,IRCCS Multimedica, Sesto San Giovanni, Milan, Italy
| | - Carmine Zoccali
- CNR-IFC, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
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Osborn JW, Banek CT. Catheter-Based Renal Nerve Ablation as a Novel Hypertension Therapy: Lost, and Then Found, in Translation. Hypertension 2018; 71:383-388. [PMID: 29295850 DOI: 10.1161/hypertensionaha.117.08928] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- John W Osborn
- From the Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis.
| | - Christopher T Banek
- From the Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis
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Howden EJ, East C, Lawley JS, Stickford AS, Verhees M, Fu Q, Levine BD. Integrative Blood Pressure Response to Upright Tilt Post Renal Denervation. Am J Hypertens 2017; 30:632-641. [PMID: 28338768 DOI: 10.1093/ajh/hpx018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 02/03/2017] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Whether renal denervation (RDN) in patients with resistant hypertension normalizes blood pressure (BP) regulation in response to routine cardiovascular stimuli such as upright posture is unknown. We conducted an integrative study of BP regulation in patients with resistant hypertension who had received RDN to characterize autonomic circulatory control. METHODS Twelve patients (60 ± 9 [SD] years, n = 10 males) who participated in the Symplicity HTN-3 trial were studied and compared to 2 age-matched normotensive (Norm) and hypertensive (unmedicated, HTN) control groups. BP, heart rate (HR), cardiac output (Qc), muscle sympathetic nerve activity (MSNA), and neurohormonal variables were measured supine, and 30° (5 minutes) and 60° (20 minutes) head-up-tilt (HUT). Total peripheral resistance (TPR) was calculated from mean arterial pressure and Qc. RESULTS Despite treatment with RDN and 4.8 (range, 3-7) antihypertensive medications, the RDN had significantly higher supine systolic BP compared to Norm and HTN (149 ± 15 vs. 118 ± 6, 108 ± 8 mm Hg, P < 0.001). When supine, RDN had higher HR, TPR, MSNA, plasma norepinephrine, and effective arterial elastance compared to Norm. Plasma norepinephrine, Qc, and HR were also higher in the RDN vs. HTN. During HUT, BP remained higher in the RDN, due to increases in Qc, plasma norepinephrine, and aldosterone. CONCLUSION We provide evidence of a possible mechanism by which BP remains elevated post RDN, with the observation of increased Qc and arterial stiffness, as well as plasma norepinephrine and aldosterone levels at approximately 2 years post treatment. These findings may be the consequence of incomplete ablation of sympathetic renal nerves or be related to other factors.
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Affiliation(s)
- Erin J. Howden
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Cara East
- Baylor Soltero Cardiovascular Research Center, Baylor Scott and White Research Institute, Dallas, Texas, USA
| | - Justin S. Lawley
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Abigail S.L. Stickford
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Myrthe Verhees
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
| | - Qi Fu
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Benjamin D. Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Kindermann I, Wedegärtner SM, Mahfoud F, Weil J, Brilakis N, Ukena J, Ewen S, Linz D, Fahy M, Mancia G, Böhm M. Improvement in health-related quality of life after renal sympathetic denervation in real-world hypertensive patients: 12-month outcomes in the Global SYMPLICITY Registry. J Clin Hypertens (Greenwich) 2017; 19:833-839. [PMID: 28480523 DOI: 10.1111/jch.13007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/27/2017] [Accepted: 02/13/2017] [Indexed: 01/21/2023]
Abstract
Renal denervation has been shown to reduce blood pressure in patients with uncontrolled hypertension, but less is known about its impact on quality of life. This analysis evaluated 12-month blood pressure and quality of life outcomes in 934 patients from the Global SYMPLICITY Registry who completed the EuroQoL five-dimensions three-level questionnaire (EQ-5D-3L). At baseline, 32% of patients reported anxiety/depression and 48% reported pain/discomfort. At 12 months (n=496), office and 24-hour ambulatory systolic blood pressure were reduced by 13.9±26.6 and 7.7±19.3 mm Hg, respectively, and 8% (P<.001) more patients reported no problems in anxiety/depression. Furthermore, numerically more patients reported no problems in pain/discomfort (4%, P=.08). Perceived health-related quality of life (visual analog scale) improved from baseline to 12 months (68±18 vs 73±17, P<.001), and the improvement was largest among patients with severe anxiety/depression at baseline (50±24 vs 64±22, P=.005 [n=32]). In this analysis, renal denervation was associated with a significant improvement in health-related quality of life, particularly anxiety/depression.
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Affiliation(s)
- Ingrid Kindermann
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Universität des Saarlandes, Homburg, Germany
| | - Sonja Maria Wedegärtner
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Universität des Saarlandes, Homburg, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Universität des Saarlandes, Homburg, Germany.,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Joachim Weil
- Medizinische Klinik II, Sana Kliniken Lübeck GmbH, Lübeck, Germany
| | | | - Julia Ukena
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Universität des Saarlandes, Homburg, Germany
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Universität des Saarlandes, Homburg, Germany
| | - Dominik Linz
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Universität des Saarlandes, Homburg, Germany
| | - Martin Fahy
- Clinical Research, Medtronic, Santa Rosa, CA, USA
| | | | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Universität des Saarlandes, Homburg, Germany
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Abstract
BACKGROUND Resistant hypertension is highly prevalent among the general hypertensive population and the clinical management of this condition remains problematic. Different approaches, including a more intensified antihypertensive therapy, lifestyle modifications, or both, have largely failed to improve patients' outcomes and to reduce cardiovascular and renal risk. As renal sympathetic hyperactivity is a major driver of resistant hypertension, renal sympathetic ablation (renal denervation) has been recently proposed as a possible therapeutic alternative to treat this condition. OBJECTIVES We sought to evaluate the short- and long-term effects of renal denervation in individuals with resistant hypertension on clinical end points, including fatal and non-fatal cardiovascular events, all-cause mortality, hospital admissions, quality of life, blood pressure control, left ventricular hypertrophy, cardiovascular and metabolic profile, and kidney function, as well as the potential adverse events related to the procedure. SEARCH METHODS We searched the following databases to 17 February 2016 using relevant search terms: the Cochrane Hypertension Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and ClinicalTrials.gov SELECTION CRITERIA: We considered randomised controlled trials (RCTs) that compared renal denervation to standard therapy or sham procedure to treat resistant hypertension, without language restriction. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed study risks of bias. We summarised treatment effects on available clinical outcomes and adverse events using random-effects meta-analyses. We assessed heterogeneity in estimated treatment effects using Chi² and I² statistics. We calculated summary treatment estimates as a mean difference (MD) or standardised mean difference (SMD) for continuous outcomes, and a risk ratio (RR) for dichotomous outcomes, together with their 95% confidence intervals (CI). MAIN RESULTS We found 12 eligible studies (1149 participants). In four studies, renal denervation was compared to sham procedure; one study compared a proximal ablation to a complete renal artery denervation; in the remaining, renal denervation was tested against standard or intensified antihypertensive therapy.None of the included trials was designed to look at hard clinical end points as primary outcomes.When compared to control, there was low quality evidence that renal denervation did not reduce the risk of myocardial infarction (4 studies, 742 participants; RR 1.31, 95% CI 0.45 to 3.84), ischaemic stroke (4 studies, 823 participants; RR 1.15, 95% CI 0.36 to 3.72), or unstable angina (2 studies, 201 participants; RR 0.63, 95% CI 0.08 to 5.06), and moderate quality evidence that it had no effect on 24-hour ambulatory blood pressure monitoring (ABPM) systolic BP (5 studies, 797 participants; MD 0.28 mmHg, 95% CI -3.74 to 4.29), diastolic BP (4 studies, 756 participants; MD 0.93 mmHg, 95% CI -4.50 to 6.36), office measured systolic BP (6 studies, 886 participants; MD -4.08 mmHg, 95% CI -15.26 to 7.11), or diastolic BP (5 studies, 845 participants; MD -1.30 mmHg, 95% CI -7.30 to 4.69). Furthermore, low quality evidence suggested that this procedure produced no effect on either serum creatinine (3 studies, 736 participants, MD 0.01 mg/dL; 95% CI -0.12 to 0.14), estimated glomerular filtration rate (eGFR), or creatinine clearance (4 studies, 837 participants; MD -2.09 mL/min, 95% CI -8.12 to 3.95). Based on low-quality evidence, renal denervation significantly increased bradycardia episodes compared to control (3 studies, 220 participants; RR 6.63, 95% CI 1.19 to 36.84), while the risk of other adverse events was comparable or not assessable.Data were sparse or absent for all cause mortality, hospitalisation, fatal cardiovascular events, quality of life, atrial fibrillation episodes, left ventricular hypertrophy, sleep apnoea severity, need for renal replacement therapy, and metabolic profile.The quality of the evidence was low for cardiovascular outcomes and adverse events and moderate for lack of effect on blood pressure and renal function. AUTHORS' CONCLUSIONS In patients with resistant hypertension, there is low quality evidence that renal denervation does not change major cardiovascular events, and renal function. There was moderate quality evidence that it does not change blood pressure and and low quality evidence that it caused an increaseof bradycardia episodes. Future trials measuring patient-centred instead of surrogate outcomes, with longer follow-up periods, larger sample size and more standardized procedural methods are necessary to clarify the utility of this procedure in this population.
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Affiliation(s)
- Giuseppe Coppolino
- "Pugliese‐Ciaccio" General HospitalNephrology and Dialysis UnitViale pio XCatanzaroCatanzaroItaly88100
| | - Anna Pisano
- CNR ‐ Italian National Council of ResearchInstitute of Clinical PhysiologyCNR‐IFC Via Vallone Petrara c/o Ospedali RiunitiReggio CalabriaItaly89100
| | - Laura Rivoli
- University "Magna Graecia"Department of Medical and Surgical Sciences, Nephrology and Dialysis UnitViale EuropaCatanzaroItaly88100
| | - Davide Bolignano
- CNR ‐ Italian National Council of ResearchInstitute of Clinical PhysiologyCNR‐IFC Via Vallone Petrara c/o Ospedali RiunitiReggio CalabriaItaly89100
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Cruz LGDB, Bocchi EA, Grassi G, Guimaraes GV. Neurohumoral and Endothelial Responses to Heated Water-Based Exercise in Resistant Hypertensive Patients. Circ J 2016; 81:339-345. [PMID: 28049937 DOI: 10.1253/circj.cj-16-0870] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The neurohumoral and endothelial responses to the blood pressure (BP) lowering effects of heated water-based exercise (HEx) in resistant hypertension (HT) patients remain undefined.Methods and Results:We investigated these in 44 true resistant HT patients (age 53.3±0.9 years, mean±SEM). They were randomized and allocated to 2 groups, 28 to a HEx training protocol, which consisted of callisthenic exercises and walking in a heated pool for 1 h, three times weekly for 12 weeks and 16 patients to a control group maintaining their habitual activities. Measurements made before and after 12 weeks of HEx included clinic and 24-h BP, plasma levels of nitric oxide, endothelin-1, aldosterone, renin, norepinephrine and epinephrine, as well as peak V̇O2, and endothelial function (reactive hyperemia). After 12 weeks of HEx patients showed a significant decrease in clinic and 24-h systolic and diastolic BPs. Concomitantly, nitric oxide increased significantly (from 25±8 to 75±24 μmol/L, P<0.01), while endothelin-1 (from 41±5 to 26±3 pg/mL), renin (from 35±4 to 3.4±1 ng/mL/h), and norepinephrine (from 720±54 to 306±35 pg/mL) decreased significantly (P<0.01). Plasma aldosterone also tended to decrease, although not significantly (from 101±9 to 76±4 pg/mL, P=NS). Peak V̇O2increased significantly after HEx (P<0.01), while endothelial function was unchanged. No significant change was detected in the control group. CONCLUSIONS The BP-lowering effects of HEx in resistant HT patients were accompanied by a significant reduction in the marked neurohumoral activation characterizing this clinical condition.
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Affiliation(s)
- Lais Galvani de Barros Cruz
- Laboratory of Physical Activity and Health Heart Institute, Clinical Hospital, Department of Medicine, Sao Paulo University
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Gao J, Kerut EK, Smart F, Katsurada A, Seth D, Navar LG, Kapusta DR. Sympathoinhibitory Effect of Radiofrequency Renal Denervation in Spontaneously Hypertensive Rats With Established Hypertension. Am J Hypertens 2016; 29:1394-1401. [PMID: 27538721 DOI: 10.1093/ajh/hpw089] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 07/22/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Radiofrequency ablation of the renal arteries (RF-ABL) has been shown to decrease blood pressure (BP) in drug-resistant hypertensive patients who receive antihypertensive drug therapy. However, there remain questions regarding how RF-ABL influences BP independent of drug therapy and whether complete renal denervation is necessary to maximally lower BP. To study these questions, we examined the cardiovascular, sympathetic, and renal effects produced by RF-ABL of the proximal renal arteries in spontaneously hypertensive rats (SHR) with established hypertension. METHODS SHR were instrumented (telemetry) for measurement of systolic/diastolic BP (SBP/DBP). Rats then underwent Sham-ABL or RF-ABL adjacent to the renal ostium and BP was recorded for 8 weeks. Changes in sympathetic activity, 24-hour water/sodium excretion, and levels of urinary angiotensinogen (AGT), plasma renin activity, and kidney renin content (KRC) were measured in SHR. RESULTS Compared with Sham-ABL, RF-ABL produced a sustained decrease in BP. At 8 weeks, SBP/DBP was 171±6/115±3 and 183±4/129±3mm Hg for RF-ABL and Sham-ABL SHR, respectively. Correlating with the reduction in BP, RF-ABL significantly decreased the low frequency/total and low frequency/high frequency of BP variability and attenuated the hypotensive response to chlorisondamine. Kidney norepinephrine levels were markedly decreased at 8 weeks in RF-ABL vs. Sham-ABL SHR. There were no group differences in 24-hour sodium/water excretion or urinary AGT excretion rate (6 weeks) or plasma renin activity or KRC (8 weeks). In other studies, concurrent RF-ABL plus surgical denervation initially decreased BP to a greater level than RF-ABL alone, but thereafter the reduction in BP between groups was not different. CONCLUSIONS In hypertensive SHR, bilateral RF-ABL of the proximal renal arteries produced a sustained decease in sympathetic activity and BP without changes in sodium/water excretion or activity of the systemic/renal renin-angiotensin system.
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Affiliation(s)
- Juan Gao
- The Department of Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
- The Cardiovascular Center of Excellence, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | | | - Frank Smart
- The Cardiovascular Center of Excellence, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
- Department of Cardiology, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | - Akemi Katsurada
- The Department of Physiology and the Hypertension and Renal Center of Excellence, Tulane Health Sciences Center, New Orleans, Louisiana, USA
| | - Dale Seth
- The Department of Physiology and the Hypertension and Renal Center of Excellence, Tulane Health Sciences Center, New Orleans, Louisiana, USA
| | - L Gabriel Navar
- The Department of Physiology and the Hypertension and Renal Center of Excellence, Tulane Health Sciences Center, New Orleans, Louisiana, USA
| | - Daniel R Kapusta
- The Department of Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
- The Cardiovascular Center of Excellence, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
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Howden EJ, Lawley JS, Esler M, Levine BD. Potential role of endurance training in altering renal sympathetic nerve activity in CKD? Auton Neurosci 2016; 204:74-80. [PMID: 27908698 DOI: 10.1016/j.autneu.2016.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 11/16/2016] [Accepted: 11/23/2016] [Indexed: 12/20/2022]
Abstract
Chronic kidney disease (CKD), is characterized by a progressive loss of renal function and increase in cardiovascular risk. In this review paper, we discuss the pathophysiology of increased sympathetic nerve activity in CKD patients and raise the possibility of endurance exercise being an effective countermeasure to address this problem. We specifically focus on the potential role of endurance training in altering renal sympathetic nerve activity as increased renal sympathetic nerve activity negatively impacts kidney function as well indirectly effects multiple other systems and organs. Recent technological advances in device based therapy have highlighted the detrimental effect of elevated renal sympathetic nerve activity in CKD patients, with kidney function and blood pressure being improved post renal artery nerve denervation in selected patients. These developments provide optimism for the development of alternative and/or complementary strategies to lower renal sympathetic nerve activity. However, appropriately designed studies are required to confirm preliminary observations, as the widespread use of the renal denervation approach to lower sympathetic activity presently has limited feasibility. Endurance training may be one alternative strategy to reduce renal sympathetic nerve activity. Here we review the role of endurance training as a potential alternative or adjunctive to current therapy in CKD patients. We also provide recommendations for future research to assist in establishing an evidence base for the use of endurance training to lower renal sympathetic activity in CKD patients.
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Affiliation(s)
- Erin J Howden
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, TX 75231, United States; University of Texas Southwestern Medical Center, Dallas, TX 75231, United States; Baker IDI Heart and Diabetes Institute, Melbourne, VIC 3004, Australia.
| | - Justin S Lawley
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, TX 75231, United States; University of Texas Southwestern Medical Center, Dallas, TX 75231, United States
| | - Murray Esler
- Baker IDI Heart and Diabetes Institute, Melbourne, VIC 3004, Australia
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, TX 75231, United States; University of Texas Southwestern Medical Center, Dallas, TX 75231, United States
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Grassi G, Ram VS. Evidence for a critical role of the sympathetic nervous system in hypertension. ACTA ACUST UNITED AC 2016; 10:457-66. [DOI: 10.1016/j.jash.2016.02.015] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 02/22/2016] [Accepted: 02/25/2016] [Indexed: 02/07/2023]
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Gronda E, Brambilla G, Seravalle G, Maloberti A, Cairo M, Costantino G, Lovett E, Vanoli E, Mancia G, Grassi G. Effects of chronic carotid baroreceptor activation on arterial stiffness in severe heart failure. Clin Res Cardiol 2016; 105:838-46. [PMID: 27120329 DOI: 10.1007/s00392-016-0992-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 04/22/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Heart failure with reduced ejection fraction (HFrEF) is characterized by activation of the sympathetic nervous system and increased arterial stiffness, leading to an impaired ventricular-vascular coupling. Baroreflex activation therapy (BAT) has been shown to reduce muscle sympathetic nerve activity (MSNA) and improve clinical status of patients with HFrEF. The purpose of this investigation was to determine the effects of BAT on arterial stiffness in HFrEF. METHODS AND RESULTS MSNA, clinical variables, and parameters of central blood pressure (BP) and arterial stiffness were collected in 18 NYHA Class III HFrEF patients, nine receiving BAT and nine continuing with optimal medical management alone. Patients were followed for 3 months, with measurements at that time compared to baseline evaluation. Baseline characteristics of the groups were well matched. At 3 months, BAT did not improve central BP and arterial stiffness despite a significant amelioration of MSNA, NYHA class, Minnesota living with heart failure questionnaire score, number of heart failure medications and six-minute walking distance. The control group exhibited no significant changes in all the measured variables. CONCLUSIONS Despite significant reductions in MSNA and clinical improvement, BAT does not appear to chronically modify arterial stiffness within this HFrEF cohort. Additional study is required to determine if this result applies to the HFrEF population as a whole.
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Affiliation(s)
- Edoardo Gronda
- Cardiovascular Department, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy
| | - GianMaria Brambilla
- Clinica Medica, University of Milano-Bicocca, Via Pergolesi 33, 20090, Monza, Italy
| | | | - Alessandro Maloberti
- Clinica Medica, University of Milano-Bicocca, Via Pergolesi 33, 20090, Monza, Italy
| | - Matteo Cairo
- Clinica Medica, University of Milano-Bicocca, Via Pergolesi 33, 20090, Monza, Italy
| | - Giuseppe Costantino
- Cardiovascular Department, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy
| | | | - Emilio Vanoli
- Cardiovascular Department, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy
| | | | - Guido Grassi
- Cardiovascular Department, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy. .,Clinica Medica, University of Milano-Bicocca, Via Pergolesi 33, 20090, Monza, Italy.
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