Modulation of renal sympathetic innervation: recent insights beyond blood pressure control

Abstract

Renal afferent and efferent sympathetic nerves are involved in the regulation of blood pressure and have a pathophysiological role in hypertension. Additionally, several conditions that frequently coexist with hypertension, such as heart failure, obstructive sleep apnea, atrial fibrillation, renal dysfunction, and metabolic syndrome, demonstrate enhanced sympathetic activity. Renal denervation (RDN) is an approach to reduce renal and whole body sympathetic activation. Experimental models indicate that RDN has the potential to lower blood pressure and prevent cardio-renal remodeling in chronic diseases associated with enhanced sympathetic activation. Studies have shown that RDN can reduce blood pressure in drug-naïve hypertensive patients and in hypertensive patients under drug treatment. Beyond its effects on blood pressure, sympathetic modulation by RDN has been shown to have profound effects on cardiac electrophysiology and cardiac arrhythmogenesis. RDN can display anti-arrhythmic effects in a variety of animal models for atrial fibrillation and ventricular arrhythmias. The first non-randomized studies demonstrate that RDN may promote the maintenance of sinus rhythm following catheter ablation in patients with atrial fibrillation. Registry data point towards a beneficial effect of RDN to prevent ventricular arrhythmias in patients with heart failure and electrical storm. Further large randomized placebo-controlled trials are needed to confirm the antihypertensive and anti-arrhythmic effects of RDN. Here, we will review the current literature on anti-arrhythmic effects of RDN with the focus on atrial fibrillation and ventricular arrhythmias. We will discuss new insights from preclinical and clinical mechanistic studies and possible clinical implications of RDN.

Renal nerve ablation for resistant hypertension: facts, fictions and future directions

“…Solid evidence has accumulated indicating that a deranged renal sympathetic activity could be detrimental in a series of other pathological conditions including renal disease, arrhythmias, obstructive sleep apnea, and metabolic syndrome (Linz et al, 2018). Future therapeutic targets of renal nerve ablation could move beyond the treatment of resistant hypertension.…”

Renal denervation in patients with heart failure secondary to Chagas' disease: A pilot randomized controlled trial

“…A recent meta‐analysis of relatively small feasibility studies suggests that renal denervation may improve left ventricular function in patients with dilated heart disease . In addition, the potential of renal denervation in reducing atrial fibrillation and ventricular arrhythmias has been shown in a variety of animal models . Thus far, however, the impact of renal denervation has not been evaluated in Chagas cardiomyopathy.…”

“…18 In addition, the potential of renal denervation in reducing atrial fibrillation and ventricular arrhythmias has been shown in a variety of animal models. 21 Thus far, however, the impact of renal denervation has not been evaluated in Chagas cardiomyopathy.…”

Neurogenic hypertension: introduction to the series

“…In their state-of-the-art review, Linz and colleagues discuss the relevance of renal afferent and efferent sympathetic nerves in blood regulation and hypertension, with focus on the potential of and lessons learned from renal denervation [6]. They further analyze the comorbidities of hypertension that also share sympathetic hyperactivity, such as heart failure, sleep apnea, and atrial fibrillation, and how renal modulation can not only be beneficial for the treatment of hypertension, but also for the management of life-threatening arrhythmias.…”