Renal denervation using carbon dioxide renal angiography in patients with uncontrolled hypertension and moderate to severe chronic kidney disease

Abstract

BackgroundChronic kidney disease (CKD) is the most common cause of secondary hypertension. More than half of the patients have uncontrolled hypertension (≥140/90 mmHg on three or more antihypertensive agents at optimum doses). Renal sympathetic denervation (RSDN) has been shown to reduce blood pressure (BP) in patients with resistant hypertension. Although patients with CKD have high sympathetic drive, all major clinical trials have excluded patients with estimated glomerular filtration rates (eGFRs) <45 mL/min/1.73m2 for risk of contrast-induced nephropathy.MethodsIn this pilot study, carbon dioxide (CO2) was used as the sole contrast agent to carry out renal angiography and RSDN in patients with moderate to severe CKD (eGFR 15–44 mL/min/1.73m2) and uncontrolled hypertension.ResultsEleven patients (eight males) underwent RSDN. The median age was 57 years [interquartile range (IQR) 49–66]. The median number of antihypertensives being taken at baseline was 4 (IQR 3–4). No statistically significant difference was observed in serum creatinine in the serial follow-ups until at 6 months[median difference 0.25 mg/dL (IQR 0.09–0.53); P = 0.008]. There was a non-significant reduction in median clinic BP from baseline to 6 months [−14 mmHg (IQR −24–5)] and a significant increase in daytime ambulatory systolic BP [7 mmHg (IQR −2–12); P= 0.045]. A trend towards a serial reduction in albuminuria was observed. Procedure-related complications included a groin haematoma (n = 1) and reported flank (n = 1) and groin pain (n = 1).ConclusionsThis pilot study shows that CO2 renal angiography can be used to perform RSDN in patients with significant renal impairment and may lead to associated improvements in clinic BP and albuminuria.

Efficacy and safety of renal denervation for hypertension in patients with chronic kidney disease: a meta-analysis

“…Of the 35 studies included in the full-text evaluation, seven were excluded because they were case reports, three were excluded because of the study protocol, two were excluded for insufficient data, two were excluded for duplicate patient data, and 10 did not meet the inclusion criteria. Finally, 11 single-center, non-randomized, uncontrolled studies were included in the meta-analysis (Figure 1) [18][19][20][21][22][23][24][25][26][27][28]. These 11 studies included 238 patients and are summarized in Table 1.…”

“…As shown in Table 4, two articles reported eGFR values at 1 month [21,23], four articles reported eGFR values at 3 months and 6 months [18,21,23,27], three articles reported eGFR values at 12 months [20,21,27], and two articles reported eGFR values at 24 months after RDN [21,27]. The heterogeneity among the studies was significant; therefore, the random-effects model was used for the analysis (Table 4).…”

“…Data on UACR levels were reported in four studies [18,21,23,27] (Table 4). UACR levels were significantly reduced at 3 months and 6 months after RDN (all, p < 0.001).…”

“…Three major complications (hematoma, femoral pseudoaneurysm, and bleeding) were reported after RDN [19,21,23,25]. Only one article reported the data of the bleeding complication [21].…”

Renal artery intervention utilizing carbon dioxide angiography

“…In this issue of Clinical Kidney Journal , Hameed et al [ 1 ] present feasibility data for carbon dioxide (CO 2 ) angiography during renal denervation in 11 patients with estimated glomerular filtration rates <45 mL/min/1.73 m 2 . In brief, the image guidance is safe and effective.…”