Resistant hypertension is associated with chronic activation of the sympathetic nervous system resulting in various comorbidities. The prevalence of resistant hypertension is often under estimated due to various reasons. Activation of sympathetic nervous system at the renal- as well as systemic- level contributes to the increased level of catecholamines and resulting increase in the blood pressure. This increased activity was demonstrated by increased muscle sympathetic nerve activity and renal and total body noradrenaline spillover. Apart from the hypertension, it is hypothesized to be associated with insulin resistance, congestive heart failure and obstructive sleep apnea. Renal denervation is a novel procedure where the sympathetic afferent and efferent activity is reduced by various techniques and has been used successfully to treat drug-resistant hypertension improvement of various metabolic derangements. Renal denervation has the unique advantage of offering the denervation at the renal level, thus mitigating the systemic side effects. Renal denervation can be done by various techniques including radiofrequency ablation, ultrasound guided ablation and chemical ablation. Various trials evaluated the role of renal denervation in the management of resistant hypertension and have found promising results. More studies are underway to evaluate the role of renal denervation in patients presenting with resistant hypertension in different scenarios. Appropriate patient selection might be the key in determining the effectiveness of the procedure.
Patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) on dialysis have an increased risk for cardiovascular mortality and morbidity secondary to occlusive coronary artery disease. Optimal revascularization strategy is unclear in this high-risk population. We have performed a meta-analysis to compare coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in patients with ESRD and CKD. We searched PubMed, Ovid, MEDLINE, CINAHL, and EMBASE (1980-2013) and found 17 trials (N = 33,584) in the ESRD arm and 6 studies (n = 15,493) in the CKD arm. Two investigators independently collected the data. All the studies were retrospective trials. In the ESRD and CKD groups, we found significantly reduced early mortality with the PCI group with the odds ratio of 2.08 (1.90-2.26; P < 0.00001) and 2.55 (1.45-4.51; P = 0.001), respectively. Contrary to the early mortality results, we found decreased late mortality with the CABG group when compared with the PCI group [odds ratio: 0.86 (0.83-0.89; P < 0.000001) and 0.82 (0.76-0.88; P < 0.00001)] in the ESRD and CKD arm, respectively. When compared with PCI, there was decreased cardiovascular mortality with an odds ratio of 0.61 (0.40-0.92; P = 0.02) in patients who underwent CABG in ESRD population. Similar trends were observed in the incidence of myocardial infarction and repeat revascularization. There is a strong trend for decreased risk of stroke with PCI when compared with CABG in ESRD and CKD populations.
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