Is renal sympathetic denervation (RSD) recommended for patients with end-stage kidney disease (ESKD)?

Renal Sympathetic Denervation in End-Stage Kidney Disease

Renal sympathetic denervation (RSD) can be performed in patients with end-stage kidney disease (ESKD), but it is not recommended as standard care and should only be considered in highly selected patients with resistant hypertension at experienced centers.

Current Guideline Position

The most recent European Society of Cardiology guidelines explicitly exclude patients with moderate to severe renal impairment (eGFR <40 mL/min/1.73 m²) from routine renal denervation 1. This recommendation is based on:

• Lack of adequately powered outcomes trials demonstrating safety and cardiovascular benefits in this population 2
• Classification of radiofrequency ablation of renal sympathetic nerves as investigational for uncontrolled hypertension 2
• Recommendation that device-based therapies should not be routine treatment unless in the context of clinical studies 2

Evidence in ESKD Patients

Despite guideline restrictions, emerging research data suggest potential feasibility and efficacy:

Safety Profile

• Multiple small studies demonstrate that bilateral RSD can be performed successfully in ESKD patients without peri- or post-procedural complications 3, 4
• Renal function (as measured by dialysis parameters) remains stable after the procedure 3
• The procedure is feasible even in patients with challenging anatomy, including small vessel diameters 4

Blood Pressure Reduction

• Significant 24-hour ambulatory BP reductions have been documented: -20/-15 mmHg at 6 months 3 and -24/-13 mmHg at 12 months 5
• Office BP reductions occur as early as 1 month post-procedure (systolic: -25 mmHg, diastolic: -13 mmHg) 5
• Night-time ambulatory BP significantly decreases, restoring more physiologic dipping patterns 6

Cardiovascular Benefits

• RSD reduces muscle sympathetic nervous activity (MSNA) by -12.2 bursts/min at 12 months 5
• Left ventricular mass decreases by -27 g/m² at 12 months, addressing the high prevalence of left ventricular hypertrophy in ESKD 5
• These effects target the markedly elevated sympathetic neural activation characteristic of ESKD 5

Clinical Decision-Making Algorithm

If considering RSD in ESKD patients, the following criteria must be met:

1. Confirmed resistant hypertension - Uncontrolled BP on ≥3 antihypertensive medications including a diuretic 1, 2

2. Exclusion of pseudo-resistance - Accurate assessment of treatment adherence and confirmation of true treatment resistance 1

3. Anatomical eligibility - Absence of prior renal artery interventions, vessel stenosis <70%, or extended calcifications (>30% of vessel circumference) 4

4. Center expertise - Procedure should only be performed at medium-to-high volume centers 1, 2

5. Research context preferred - Given investigational status, enrollment in clinical trials or registries is strongly encouraged 2

Important Caveats

• All current evidence in ESKD comes from small pilot studies (n=4-15 patients) with short-term follow-up 3, 4, 5, 6
• The procedure remains investigational specifically for ESKD patients, despite promising preliminary results 7
• Multidisciplinary assessment and thorough risk-benefit discussion are mandatory before proceeding 1
• CO₂ angiography can be used to minimize contrast exposure in patients with residual renal function 6

Key Pitfall to Avoid

Do not perform RSD as first-line therapy or in place of optimized medical management. The European guidelines are clear that intensification of lifestyle measures (particularly sodium restriction), addition of low-dose spironolactone, and optimization of other antihypertensive agents must be attempted first 2. RSD should only be considered after these measures have failed in the context of true resistant hypertension 1, 2.