What are the indications for renal artery denervation in patients with hypertension?

Indications for Renal Artery Denervation

Renal artery denervation should be considered as an adjunctive treatment option only in highly selected patients with resistant hypertension who remain uncontrolled despite taking at least three antihypertensive medications (including a thiazide or thiazide-like diuretic at adequate doses), after excluding secondary causes and maximizing pharmacologic therapy including mineralocorticoid receptor antagonists. 1

Patient Selection Criteria

Primary Indication

• Resistant hypertension defined as uncontrolled blood pressure on three or more medications, including a diuretic at appropriate doses 1
• The European Society of Cardiology specifically recommends this procedure only after shared decision-making and multidisciplinary assessment 1

Additional Considerations for Revascularization (Not Denervation)

Note that the guidelines distinguish between renal artery revascularization (for stenosis) and renal artery denervation (for resistant hypertension). For revascularization specifically:

• Refractory hypertension (uncontrolled BP on ≥5 drugs including a diuretic) 2
• Worsening renal function (ischemic nephropathy) 2
• Intractable heart failure 2

Mandatory Prerequisites Before Consideration

Exclusion of Secondary Causes

Secondary causes of hypertension must be thoroughly excluded before proceeding 1. Look specifically for:

• Sleep apnea (snoring, daytime sleepiness, non-restorative sleep) 2
• Primary aldosteronism (unprovoked hypokalemia, approximately 20% prevalence in resistant hypertension) 2
• Renovascular disease 2
• Pheochromocytoma, Cushing's syndrome, or other endocrine disorders 2

Optimization of Medical Therapy

• All patients must have maximized pharmacologic therapy, specifically including consideration of spironolactone or other mineralocorticoid receptor antagonists before denervation is considered 1
• Ensure adherence to at least three medications including a thiazide/thiazide-like diuretic 1
• Confirm true resistant hypertension with 24-hour ambulatory blood pressure monitoring to exclude white coat hypertension 2

Absolute Contraindications

Renal Function

• Moderate to severe renal impairment with eGFR <40 mL/min/1.73 m² is a contraindication 1
• The procedure demonstrates no significant changes in serum creatinine or eGFR in appropriate candidates 1

Anatomical Considerations

• While the procedure can be performed safely regardless of renal anatomy, patients with bilateral single renal arteries demonstrate more pronounced blood pressure and sympathetic nerve activity reduction compared to those with dual renal arteries 3
• Patients with dual renal arteries may require ablation in all arteries to achieve adequate response 3

Procedural Requirements

Center Volume and Expertise

• Renal denervation should only be performed at medium-to-high volume centers with appropriate expertise 1
• The procedure demonstrates a good safety profile with no severe complications reported in recent systematic reviews 1

Important Caveats

Evidence Quality Limitations

• Current evidence shows no significant reduction in major cardiovascular events (myocardial infarction, stroke, unstable angina) with renal denervation compared to control 4
• Moderate quality evidence demonstrates no significant effect on 24-hour ambulatory blood pressure (MD 0.28 mmHg systolic, 95% CI -3.74 to 4.29) 4
• Low quality evidence shows an increased risk of bradycardia episodes (RR 6.63,95% CI 1.19 to 36.84) compared to control 4

Recent FDA Approval

• The FDA has recently approved specific systems (ReCor Medical Paradise system and Symplicity Spyral RDN systems) for renal artery denervation 5
• This represents evolving technology with ongoing refinement of techniques and patient selection 5

Clinical Reality

Given the moderate-to-low quality evidence showing minimal blood pressure reduction and no improvement in hard cardiovascular outcomes, renal denervation should be reserved for truly refractory cases where all other options have been exhausted, and only after thorough multidisciplinary evaluation at experienced centers 1, 4. The procedure's role remains investigational for improving patient-centered outcomes despite recent FDA approvals 4, 5.