Renal denervation for human hypertension: is there a future?

Area of Science:

• Cardiovascular Medicine
• Nephrology
• Hypertension Research

Background:

• The sympathetic nervous system is implicated in the development and maintenance of human essential hypertension.
• Excessive sympathetic nervous system activity is prominent in early hypertension stages, including prehypertension and white-coat hypertension.
• Renal nerves play a crucial role in regulating the renin-angiotensin system and renal sodium excretion, making them a target for hypertension management.

Purpose of the Study:

• To explore the role of renal denervation in managing hypertension, particularly in light of conflicting results from human trials.
• To discuss whether renal denervation is more effective in preventing hypertension onset versus treating established, resistant hypertension.
• To identify potential anatomical or technical challenges hindering the efficacy of renal denervation procedures in humans.

Main Methods:

• Review of animal models demonstrating the efficacy of renal denervation in ameliorating various forms of induced hypertension.
• Analysis of human clinical trials, including the SYMPLICITY HTN-3 trial, investigating catheter ablation of renal nerves in resistant hypertension.
• Expert discussion on the potential limitations and future directions for renal denervation as a therapeutic strategy.

Main Results:

• Renal denervation effectively reduced hypertension in multiple animal models, including renovascular, spontaneously hypertensive, and steroid-induced hypertension.
• The SYMPLICITY HTN-3 trial, a rigorously controlled study in resistant hypertension, did not demonstrate significant long-term blood pressure reduction following renal denervation.
• The efficacy of renal denervation in humans remains uncertain, with questions raised about its optimal application and procedural challenges.

Conclusions:

• Renal denervation's effectiveness in treating established human hypertension requires further investigation, potentially focusing on earlier intervention stages.
• Technical and anatomical factors may present barriers to successful renal denervation in clinical practice.
• The role of renal denervation in hypertension management is a complex issue, necessitating continued research and expert debate.