Renal Denervation for Uncontrolled and Resistant Hypertension: Systematic Review and Network Meta-Analysis of Randomized Trials

Cost-effectiveness analysis of radiofrequency renal denervation for uncontrolled hypertension in Canada

AIMS

Catheter-based radiofrequency renal denervation (RF RDN) is an interventional treatment for uncontrolled hypertension. This analysis explored the therapy's lifetime cost-effectiveness in a Canadian healthcare setting.

MATERIALS AND METHODS

A decision-analytic Markov model was used to project health events, costs, and quality-adjusted life years over a lifetime horizon. Seven primary health states were modeled, including hypertension alone, stroke, myocardial infarction (MI), other symptomatic coronary artery disease, heart failure (HF), end-stage renal disease (ESRD), and death. Multivariate risk equations and a meta-regression of hypertension trials informed transition probabilities. Contemporary clinical evidence from the SPYRAL HTN-ON MED trial informed the base case treatment effect (-4.9 mmHg change in office systolic blood pressure (oSBP) observed vs. sham control). Costs were sourced from published literature. A 1.5% discount rate was applied to costs and effects, and the resulting incremental cost-effectiveness ratio (ICER) was evaluated against a willingness-to-pay threshold of $50,000 per QALY gained. Extensive scenario and sensitivity analyses were performed.

RESULTS

Over 10 years, RF RDN resulted in relative risk reduction in clinical events (0.80 for stroke, 0.88 for MI, and 0.72 for HF). Under the base case assumptions, RF RDN was found to add 0.51 (15.81 vs. 15.30) QALYs at an incremental cost of $6,031 ($73,971 vs. $67,040) over a lifetime, resulting in an ICER of $11,809 per QALY gained. Cost-effectiveness findings were found robust in sensitivity analyses, with the 95% confidence interval for the ICER based on 10,000 simulations ranging from $4,489 to $22,587 per QALY gained.

LIMITATIONS AND CONCLUSION

Model projections suggest RF RDN, under assumed maintained treatment effect, is a cost-effective treatment strategy for uncontrolled hypertension in the Canadian healthcare system based on meaningful reductions in clinical events.

Renal Denervation Effects on Blood Pressure in Resistant and Uncontrolled Hypertension: A Meta-Analysis of Sham-Controlled Randomized Clinical Trials

BACKGROUND

Although some guidelines recommend Renal denervation (RDN) as an alternative to anti-HTN medications, there are concerns about its efficacy and safety. We aimed to evaluate the benefits and harms of RDN in a systematic review and meta-analysis of sham-controlled randomized clinical trials (RCT).

METHODS

Databases were searched until September 10th, 2024, to identify RCTs evaluating RDN for treating URH versus sham control. The primary outcomes were the change in office and ambulatory 24-h systolic (SBP) and diastolic blood pressure (DBP). Secondary outcomes were changes in daytime and nighttime SBP and DBP, home BP, number of anti-HTN drugs, and related complications. Mean differences (MD) and relative risks (RR) described the effects of RDN on BP and complications, respectively, using random effects meta-analyses. GRADE methodology was used to assess the certainty of evidence (COE).

RESULTS

We found 16 included sham-controlled RCTs [RDN (n = 1594) vs. sham (n = 1225)]. RDN significantly reduced office SBP (MD -4.26 mmHg, 95% CI: -5.68 to -2.84), 24 h ambulatory SBP (MD -2.63 mmHg), office DBP (MD -2.15 mmHg), 24-h ambulatory DBP (MD -1.27 mmHg), and daytime SBP and DBP (MD -3.29 and 2.97 mmHg), compared to the sham. The rate of severe complications was low in both groups (0%-2%). The heterogeneity was high among most indices, and CoE was very low for most outcomes.

CONCLUSION

RDN significantly reduced several SBP and DBP outcomes versus sham without significantly increasing complications. This makes RDN a potentially effective alternative to medications in URH.

Comparing the Efficacy of Renal Artery Denervation in Uncontrolled Hypertension: A Systematic Review and Network Meta-Analysis

The study aims to compare the outcomes of different renal denervation (RDN) procedures in the treatment of uncontrolled hypertension. We searched Scopus, PubMed, Web of Science, and Cochrane for RCTs evaluating different procedures of RDN for hypertension. The outcomes of this study were systolic blood pressure (SBP) daytime, diastolic blood pressure (DBP) daytime, SBP nighttime, DBP nighttime, SBP 24-hour, DBP 24-hour, SBP home, DBP home, SBP office, and DBP office. We did a frequentist network meta-analysis of 38 published RCTs evaluating the efficacy of different renal artery denervation procedures for uncontrolled hypertension compared to sham procedures or standardized stepped-care antihypertensive treatment (SSAHT). Radiofrequency (RF) alone showed a statistically significant reduction in DBP (24 hours), DBP (daytime), and DBP (nighttime): standardized mean difference (SMD): -2.01 (95% CI: (-3.34; -0.68)), SMD: -4.36 (95% CI: (-8.28; -0.44)), and SMD: -3.50 (95% CI: (-6.23; -0.76)), respectively, and showed a statistically significant reduction in SBP (24 hours), SBP (daytime), and SBP (nighttime): SMD: -3.93 (95% CI: (-6.01; -1.84)), SMD: -5.88 (95% CI: (-9.91; -1.85)), and SMD: -5.79 (95% CI: (-10.0; -1.58)), respectively. RF added to SSAHT has statistical significance in the reduction of DBP (nighttime), SBP (daytime), SBP (home), and SBP (nighttime) with a SMD of -7.63 (95% CI: (-14.21; -1.06)), SMD of -10.56 (95% CI: (-21.03; -0.08)), SMD of -23.20 (95% CI: (-36.72; -9.26)), and SMD of -14.03 (95% CI: (-25.43; -2.63)), respectively. We found that renal denervation, especially by RF, when added to SSAHT may be a promising therapeutic option for patients with treatment-resistant hypertension, particularly in cases where medication alone fails to achieve adequate blood pressure control.

The Efficacy of Renal Denervation in Treating Resistant Hypertension: A Systematic Review

Resistant hypertension is blood pressure (BP) that is persistently above target in spite of the maximally tolerated usage of at least three anti-hypertensives simultaneously. The sympathetic nervous system is instrumental in blood pressure (BP) regulation. Renal (sympathetic) denervation involves using ablative energy to disrupt the sympathetic nerves in renal arteries. This systematic review examines the efficacy of this treatment modality. Abiding by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, we conducted an extensive literature search in five databases, Cochrane Library, Google Scholar, PubMed, PubMed Central (PMC), and ScienceDirect, to retrieve studies that are free, open access, and published in English done within the past four years. Nineteen articles passed critical appraisal. These articles were randomized controlled trials (RCT), a case report, a cross-sectional study, a cohort study, and previous reviews. Renal denervation (RDN) was generally superior to sham control in patients with resistant hypertension for reducing various systolic blood pressure (SBP) measures, including 24-hour ambulatory, daytime, and nighttime SBP. The efficacy was highest in patients whose baseline SBP was higher. BP reduction was sustained for years post-procedure. The procedure had a good safety profile with no severe complications. Future studies should compare the efficacy of different types of renal denervation, such as ethanol ablation versus radiofrequency ablation, and renal denervation against other procedure-based treatment modalities, such as carotid baroreceptor stimulation and transcranial direct current stimulation.

Renal denervation for uncontrolled hypertension: a systematic review and meta-analysis examining multiple subgroups

This systematic review and meta-analysis was conducted to assess the randomized controlled trial (RCT) evidence available for renal denervation (RDN) in uncontrolled arterial hypertension. Twenty-five RCTs met the eligibility criteria for the systematic review, and 16 RCTs were included in the meta-analysis. The results of the random effects meta-analysis estimated a mean difference of -8.5 mmHg [95% confidence interval (CI) -13.5 to -3.6] for office SBP, -3.6 mmHg (95% CI -5.2 to -2.0) for 24 h SBP and -3.9 mmHg (95% CI -5.6 to -2.2) for ambulatory daytime SBP in favour of RDN compared with control (medication and/or sham-only) at primary follow-up. Similarly favourable results were observed across a range of prespecified subgroup analyses, including treatment-resistant hypertension. This meta-analysis suggests that the use of RDN in uncontrolled hypertension leads to consistent reductions in blood pressure. Reductions appear to be statistically consistent in the presence or absence of medications and in populations resistant to the use of three medications.

Effects of renal denervation on kidney function in patients with chronic kidney disease: a systematic review and meta-analysis

The present study aims to evaluate the clinical outcomes following renal denervation (RDN) for hypertensive patients with chronic kidney disease (CKD). Prospective studies published between January 1, 2010 and November 15, 2022 where systematically identified for RDN outcomes on office and ambulatory blood pressure, estimated glomerular filtration rate (eGFR), creatinine and procedural characteristics from three online databases (Medline, PubMed, EMBASE). Random effects model to combine risk ratios and mean differences was used. Where possible, clinical outcomes were pooled and analyzed at 6, 12 and 24 months. Significance was set at p ≤ 0.05. 11 prospective trials, with a total of 226 patients with treatment resistant HTN receiving RDN met the inclusion criteria. Age ranged from 42.5 ± 13.8 to 66 ± 9. Main findings of this review included a reduction in systolic and diastolic office blood pressure at 6 [-19.8 (p < 0.00001)/-15.2 mm Hg (p < 0.00001)] and 12 months [-21.2 (p < 0.00001)/-9.86 mm Hg (p < 0.0005)] follow-up compared to baseline. This was also seen in systolic and diastolic 24-hour ambulatory blood pressure at 6 [-9.77 (p = 0.05)/-3.64 mm Hg (p = 0.09)] and 12 months [-13.42 (p = 0.0007)/-6.30 mm Hg (p = 0.001)] follow-up compared to baseline. The reduction in systolic and diastolic 24-hour ambulatory blood pressure was maintained to 24 months [(-16.30 (p = 0.0002)/-6.84 mm Hg (p = 0.0010)]. Analysis of kidney function through eGFR demonstrated non-significant results at 6 (+1.60 mL/min/1.73 m2, p = 0.55), 12 (+5.27 mL/min/1.73 m2, p = 0.17), and 24 months (+7.19 mL/min/1.73 m2, p = 0.36) suggesting an interruption in natural CKD progression. Similar results were seen in analysis of serum creatinine at 6 (+0.120 mg/dL, p = 0.41), 12 (+0.100 mg/dL, p = 0.70), and 24 months (+0.07 mg/dL, p = 0.88). Assessment of procedural complications deemed RDN in a CKD cohort to be safe with an overall complication rate of 4.86%. With the current advances in RDN and its utility in multiple chronic diseases beyond hypertension, the current study summarizes critical findings that further substantiate the literature regarding the potential of such an intervention to be incorporated as an effective treatment for resistant hypertension and CKD.

Renal denervation in the antihypertensive arsenal - knowns and known unknowns

Even though it has been more than a decade since renal denervation (RDN) was first used to treat hypertension and an intense effort on researching this therapy has been made, it is still not clear how RDN fits into the antihypertensive arsenal. There is no question that RDN lowers blood pressure (BP), it does so to an extent at best corresponding to one antihypertensive drug. The procedure has an excellent safety record. However, it remains clinically impossible to predict whose BP responds to RDN and whose does not. Long-term efficacy data on BP reduction are still unconvincing despite the recent results in the SPYRAL HTN-ON MED trial; experimental studies indicate that reinnervation is occurring after RDN. Although BP is an acceptable surrogate endpoint, there is complete lack of outcome data with RDN. Clear indications for RDN are lacking although patients with resistant hypertension, those with documented increase in activity of the sympathetic system and perhaps those who desire to take fewest medication may be considered.

Renal denervation for atrial fibrillation: a comprehensive updated systematic review and meta-analysis

The study aims to compare clinical outcomes following renal denervation (RDN) in hypertensive patients with atrial fibrillation (AF). Three online databases were searched (MEDLINE, EMBASE and PubMed) for literature related to outcomes of RDN on hypertension and AF, between January 1, 2010, and June 1, 2021. Where possible, risk ratios (RR) and mean differences (MD) were combined using a random effects model. Significance was set at p ≤ 0.05. Seven trials were included that assessed the effect of adding RDN to pulmonary vein isolation (PVI) in patients with hypertension and AF. A total of 711 patients (329 undergoing PVI + RDN and 382 undergoing PVI alone), with an age range of 56 ± 6 to 68 ± 9 years, were included. Pooled analysis showed a significant lowering of AF recurrence in the PVI + RDN (31.3%) group compared to the PVI-only (52.9%) group (p < 0.00001). Pooled analysis of patients with resistant hypertension showed a significant mean reduction of systolic blood pressure (SBP) (-9.42 mm Hg, p = 0.05), but not diastolic blood pressure (DBP) (-4.11 mm Hg, p = 0.16) in favor of PVI + RDN. Additionally, the pooled analysis showed that PVI + RDN significantly improved estimated glomerular filtration rate (eGFR) (+10.2 mL/min per 1.73 m2, p < 0.001) compared to PVI alone. RDN procedures in these trials have proven to be both safe and efficacious with an overall complication rate of 6.32%. Combined PVI and RDN is beneficial for patients with hypertension and AF. Combined therapy showed improvement in SBP and eGFR, reducing the risk of AF recurrence. RDN may serve as an innovative intervention in the treatment of AF.