Renal sympathetic denervation guided by renal nerve stimulation to treat ventricular arrhythmia in CKD patients with ICD

Abstract

Chronic kidney disease (CKD) patients on stage 4 present greater risk rates for malignant ventricular arrhythmia events. This study examined patients with CKD in stages 1, 2, 3 and 4, left ventricular dysfunction and automatic implantable cardioverter-defibrillator (ICD). Our goal was to record the appropriate therapies, “Anti-tachycardia Therapy Pacing” (ATP) and shock events during the 18 months of follow-up and compare the incidence and severity of these at different stages of CKD, mainly in patients with CKD stage 4 underwent renal sympathetic denervation (RSD) guided by renal nerve stimulation (RNS). One hundred and fifteen patients were evaluated once every three months till 18 months of follow-up. The arrhythmic events were assessed at each follow-up visit. Comparing the groups, we can see the number of ATP and shock events recorded by ICD during 18 months of follow-up, and differences in the number of therapeutic events between the various stages of CKD. The hazard ratio (HR), 95% confidence interval (CI) and P value for ATP and shock events between all the CKD stages were evaluated by the log-rank/Mantel-Haenszel test. At the 18th month of follow-up, 75% of patients with CKD stage 4 received ATP, and 70% were treated with shock while only 20% of the subjects with CKD stage 4 that were submitted to RSD received ATP and 20% were treated with shock, P<0.0001 and P=0.0002, respectively. In our study, a decline occurred in the incidence of arrhythmias, and therefore, appropriate ICD therapies in advanced stages of CKD, reducing the risk rates for these events in patients with CKD on stage 4 after RSD guided by RNS in comparison to the other CKD stages. Our results suggest that RSD can control the higher incidence of malignant arrhythmias in advanced CKD stages.

Renal Denervation in Asia

“…After RDN, a more blunted BP rise response with RNS was associated with greater reduction of ambulatory BP from 3 to 6 months. 81 Interestingly, studies using RNS to predict response to RDN in treatment of atrial fibrillation 82 and ventricular tachycardia 83 showed similar findings. These proof-of-concept studies involving RNS were often conducted with the use of conventional catheters designed for electrophysiology studies, followed by RDN using currently available RDN catheters.…”

Sympathetic Activation in Hypertensive Chronic Kidney Disease – A Stimulus for Cardiac Arrhythmias and Sudden Cardiac Death?

“…In a cohort of HF subjects, NT-proBNP levels were reduced by RDN, which was well tolerated and did not worsen the function of the heart and the kidneys (Hopper et al, 2017). Also, the proportion of refractory VAs and ICD shocks plunged post-RDN in another cohort with late stages of HF and CKD (Kiuchi et al, 2017).…”

New Approaches in the Management of Sudden Cardiac Death in Patients with Heart Failure—Targeting the Sympathetic Nervous System

“…In HF subjects, RDN fell NT-pro BNP concentrations and was harmless, showing no worsening of other indices of cardiac and renal function [119]. Another study reported a reduction in the rate of malignant VAs and proper ICD therapies in advanced stages of chronic kidney disease (CKD) and HF patients [120].…”

“…SNS management has emerged as a useful tool for diagnosing, preventing and treating HF, VAs, and SCD [59,120,121]. However, its configuration and clinical manifestations and disturbances are numerous and multifaceted.…”

“…Moreover, the exact mechanisms through RDN seem to reduce the burden of VAs in HF, and therefore prevent SCD events, are unknown. As RDN has had a beneficial impact on the most critical comorbidities, such as atrial fibrillation [59] and diabetes [120], prospective clinical trials are required to analyze the probable RDN advantageous effects of RDN in HF.…”