RENAL DENERVATION IN PATIENTS WITH END-STAGE KIDNEY DISEASE, A NEW OPTION TO REDUCE CARDIOVASCULAR RELATED HOSPITALIZATIONS

Refractory Hypertension (RHT) is highly prevalent among patients with End-Stage Kidney Disease (ESKD) mainly in dialysis; up to 91.4% of patients remain uncontrolled. RHT implies the inability to control blood pressure (BP) despite using four or more medications. Recent evidence has confirmed the effectiveness of renal denervation (RD) in reducing BP. RD is a neural modulation technique that aids in managing resistant systemic arterial hypertension by inhibiting sympathetic nerve stimulation, which is frequently over-stimulated as a cause of RHT in ESKD. This technique relies on endovascular devices that disrupt communication between the kidneys and the brain, reducing sympathetic activity. There is limited evidence for its use in ESKD patients, because the population with a low glomerular filtration rate has been excluded from the studies due to iodinated contrast exposure. We present our experience at our center in Bogotá, Colombia.

We provide a retrospective analysis of our RD database from 2012 to 2022. We selected patients with stage 5 chronic kidney disease (CKD), whether on dialysis or predialysis, and analyzed trends in BP and admissions to the emergency department or the intensive care unit (ICU) due to hypertensive crises before and after the procedure. We described the variables according to their nature. For qualitative variables, we calculated absolute and relative frequencies, and for quantitative variables, we summarized them using measures of central tendency and dispersion.

Between 2012 and 2014, the RD procedure was performed using the Simplicity® device (Medtronic, Minneapolis USA), on one hemodialysis (HD) patient.  From 2019 to 2022, nine patients were considered for RD, five of them had stage 5 CKD: one was in predialysis (awaiting a kidney transplant), two were on peritoneal dialysis (PD), and two were on HD. Two dialysis patients (1 HD and 1 PD) had severe bilateral renal artery stenosis and did not undergo the procedure. The other three ESKD patients received RD with a Simplicity Spyral® device (Medtronic, Minneapolis USA).

A reduction in blood pressure was observed in all treated patients, measured during HD and during nephrology clinic visits. Before undergoing RD, all patients were frequently hospitalized for hypertensive crises. Following RD, none of the patients required hospitalization. In two patients, RD was performed unilaterally due to insufficient vessel diameter. In one of them, a reduction in blood pressure was observed only during the first month, with blood pressure returning to hypertensive levels during HD. Subsequently, this patient was scheduled for a second renal denervation procedure but unfortunately experienced sudden death three months after the initial RD. One patient underwent kidney transplant, which had previously been denied due to the inadequate pre-surgical BP control and after RD was authorized based on the successful blood pressure control achieved. Remarkably, 3 years later, her graft function remains adequate without the need of antihypertensive medication.