Is renal denervation (RD) a recommended treatment for hypertension?

Renal Denervation for Hypertension

Renal denervation is not recommended as a first-line treatment for hypertension due to lack of adequately powered outcomes trials demonstrating its safety and cardiovascular disease benefits. 1

Current Recommendations for Renal Denervation

Renal denervation (RD) is a catheter-based procedure that aims to reduce blood pressure by ablating renal sympathetic nerve fibers. According to the most recent guidelines, its role in hypertension management is limited:

• RD may be considered only in specific circumstances:
  • For patients with resistant hypertension uncontrolled despite a three BP-lowering drug combination (including a thiazide or thiazide-like diuretic) 1
  • For patients with increased cardiovascular disease risk and uncontrolled hypertension on fewer than three drugs 1
  • Only after a shared risk-benefit discussion and multidisciplinary assessment 1
  • Only if performed at medium-to-high volume centers with appropriate expertise 1

Contraindications and Limitations

RD is specifically not recommended in the following situations:

• As a first-line BP-lowering intervention for hypertension 1
• In patients with moderate-to-severely impaired renal function (eGFR <40 mL/min/1.73 m²) 1
• In patients with secondary causes of hypertension 1
• For routine treatment of hypertension outside the context of clinical studies and randomized controlled trials 1

Evidence Base

The evidence supporting renal denervation has been mixed:

• Early uncontrolled studies showed promising results with large reductions in clinic BP in patients failing to control hypertension with multiple drugs 1
• However, the SYMPLICITY HTN-3 trial, the first large-scale sham-controlled clinical trial, failed to show significant difference between renal denervation and sham procedure in reducing systolic BP 1
• More recent studies with improved catheter designs have shown modest BP reductions across various hypertensive phenotypes 2

Standard Hypertension Management Approach

Before considering renal denervation, the following approach should be followed:

1. Optimize medication regimen:

   • Use a three-drug combination: ACE inhibitor/ARB + long-acting calcium channel blocker + thiazide-like diuretic 3
   • Ensure optimal dosing of all medications

2. For resistant hypertension:

   • Add spironolactone as fourth-line agent (if serum potassium <4.5 mmol/L and eGFR >45 ml/min/1.73m²) 3
   • Consider alternative agents if spironolactone is contraindicated: eplerenone, amiloride, doxazosin, or beta-blockers 3

3. Target blood pressure:

   • For most adults: systolic BP of 120-129 mmHg 1
   • For older patients (≥65 years): systolic BP of 130-139 mmHg 1
   • Diastolic BP target of <80 mmHg for all hypertensive patients 1

Pitfalls to Avoid

When considering renal denervation for hypertension management:

• Ensure true resistant hypertension is present by ruling out pseudoresistance (white coat effect, medication non-adherence, suboptimal medication choices) 3
• Screen for secondary causes of hypertension before considering RD 3
• Do not rely on RD as a substitute for comprehensive hypertension management including lifestyle modifications and appropriate pharmacotherapy 1
• Be aware that the long-term sustainability of BP reduction with RD remains uncertain 2

Renal denervation represents a developing technology that may have a role in specific hypertension cases, but current evidence does not support its widespread use as a standard treatment option for hypertension.