Yale School of Medicine, Section of Nephrology, New Haven, CT, USA.
Veterans Affairs Medical Center, Section of Nephrology, Dialysis unit, bldg 2, ground floor. 950 Campbell ave, West Haven, CT, 06516, USA.
Curr Cardiol Rep. 2022 Oct;24(10):1261-1271. doi: 10.1007/s11886-022-01753-x. Epub 2022 Jul 27.
Hypertension is a leading risk factor for all-cause mortality in adults; however, medication non-adherence and intolerance present an enormous treatment challenge. Given the critical role of renal sympathetic nerves in neurogenic control of blood pressure and pathophysiology of hypertension, renal sympathetic denervation (RDN) has been explored as a therapeutic strategy in hypertension treatment over the last 15 years. In this review, we will discuss the role of renal sympathetic nerves in the pathophysiology of hypertension, provide an update on the available evidence regarding the short- and long-term safety and effectiveness of RDN in the treatment of hypertension, and consider its future perspectives.
RDN is a percutaneous endovascular catheter-based neuromodulation approach that enables ablation of renal sympathetic nerve fibers within the adventitial layer of the renal arteries using radiofrequency (most extensively studied), ultrasound energy, or neurolytics (e.g., alcohol). In the last decade, advancements in procedural techniques and well-designed sham-controlled trials utilizing 24-h ambulatory blood pressure measurements have demonstrated that RDN has an excellent safety profile and results in a modest reduction of blood pressure, in a wide range of hypertensive phenotypes (mild to resistant), irrespective of antihypertensive drug use and this effect is sustained over a 3-year period. Superiority of a particular RDN modality has not been yet established. Despite strong evidence demonstrating efficacy and safety of RDN, current data does not support its use as a primary approach in the treatment of hypertension due to its modest treatment effect and concerns around long-term sustainability. Perhaps the best utility of RDN is in hypertensives intolerant to antihypertensive medications or as an adjunct to aldosterone antagonists in the management of resistant hypertension. Patient selection will be critical to demonstrate a meaningful benefit of RDN. Future well-designed studies are necessary to determine predictors and measures of response to RDN, long-term efficacy given question of renal nerve regeneration, comparison of available technologies, safety in patients with advanced kidney disease, and improvement in patient quality of life measures.
高血压是成年人全因死亡率的主要危险因素；然而，药物依从性差和不耐受给治疗带来了巨大的挑战。鉴于肾交感神经在神经控制血压和高血压病理生理学中的关键作用，肾去交感神经（RDN）作为高血压治疗的一种治疗策略，在过去 15 年中得到了探索。在这篇综述中，我们将讨论肾交感神经在高血压病理生理学中的作用，提供关于 RDN 治疗高血压的短期和长期安全性和有效性的最新证据，并考虑其未来前景。
RDN 是一种经皮血管内导管为基础的神经调节方法，通过射频（研究最广泛）、超声能量或神经溶解剂（如酒精）在肾动脉的外膜层消融肾交感神经纤维。在过去的十年中，程序技术的进步和精心设计的假对照试验，利用 24 小时动态血压测量，已经证明 RDN 具有极好的安全性，并且可以使血压在广泛的高血压表型（轻度至抵抗性）中适度降低，无论是否使用抗高血压药物，这种效果可持续 3 年。目前还没有确定特定 RDN 方式的优越性。尽管有强有力的证据表明 RDN 的疗效和安全性，但由于其治疗效果温和以及对长期可持续性的担忧，目前的数据并不支持将其作为高血压治疗的主要方法。RDN 的最佳用途可能是在对降压药物不耐受的高血压患者中，或作为醛固酮拮抗剂治疗难治性高血压的辅助手段。患者选择对于证明 RDN 的意义重大。未来需要进行精心设计的研究，以确定 RDN 反应的预测因素和措施、长期疗效（考虑到肾神经再生的问题）、现有技术的比较、晚期肾病患者的安全性以及患者生活质量的改善。
