Patient Selection for Renal Denervation in Hypertensive Patients: What Makes a Good Candidate?

Abstract

Renal denervation (RDN) as a therapeutic intervention in patients with hypertension has been intensively studied for over a decade, yet a critical question remains unanswered: what kind of patients are the ideal target population for RDN to achieve its maximum clinical benefit? We herein provide a review of current literature to answer questions related to patient selection to identify populations that will benefit most from RDN, drawing first from human studies but also important clues derived from preclinical animal models. Different aspects that may influence the selection of patients such as the cause of hypertension, the severity of hypertension, concurrent pharmaceutical treatment, renal function, and renal artery anatomy are discussed. Based on current evidence, patients who have severe primary hypertension, regardless of medication or degree of renal dysfunction, who have an accessible accessory renal artery, can achieve a desirable response if a thorough ablation is achieved. In preclinical models, as in humans, RDN shows variable impact, with evidence indicating it does not work in specific conditions such as reduced renal mass, salt-sensitive hypertension, and autosomal recessive polycystic kidney disease. The thresholds, however, for indicators are such that it is still not possible to reliably predict which patients could benefit from the technique. Confirmation of predictive factors and identification of biomarkers are needed before RDN can be integrated in clinical practice on clear and reliable grounds.

Renal Denervation: A Practical Guide for Health Professionals Managing Hypertension

“…2,4 RDN is also unsuitable for patients with secondary HTN from causes such as pregnancy, primary aldosteronism or valvular heart disease. 29 An algorithm summarising selection criteria for RDN is presented in Figure 2.…”

Anatomic Variations of Renal Arteries as an Important Factor in the Effectiveness of Renal Denervation in Resistant Hypertension

“…That prompts researchers to look for factors responsible for the lack of response to the procedure and to create appropriate criteria for selecting patients who will benefit from renal denervation. Many authors state that the nonresponse to the RDN is connected with the renal arteries’ anatomy [ 7 , 8 , 9 ]. Most randomized controlled trials initially enrolled patients with specified renal anatomy [ 4 , 26 , 27 ].…”

“…Lack of ablation of the accessory renal arteries (ARA) has been postulated as one of the possible causes of non-response to treatment. This paper presents the current state of knowledge on the impact of accessory renal arteries on the effectiveness of renal artery denervation [ 7 , 8 , 9 ].…”

Interventional Therapy in Refractory Hypertension: An Update

“…In addition, identifying the candidates for renal denervation therapy is probably the biggest challenge. It has been hypothesized that high baseline plasma renin activity, increased renal noradrenaline spilover rate, high baseline plasma catecholamines, baroreflex dysfunction (the loss of the baroreflex-mediated sympathetic inhibition), an increase in blood pressure during radiofrequency energy delivery, and the extent of positive change could potentially predict the procedural success of renal denervation therapy [29].…”