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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EHypertensive individuals, who cannot achieve target blood pressure (BP) levels despite being treated with triple-drug regimens, including a diuretic, are diagnosed as having resistant hypertension (rHT) [Calhoun DA et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2008], which is an increasingly common clinical problem [Egan BM et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2011]. Renal sympathetic hyperactivity is influential in the maintenance and progression of hypertension, while the interruption of sympathetic nerves in the kidney has a strong impact on BP and survival. This article discusses the impact of renal denervation as a treatment for hypertension.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiometabolic Disorder\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Radiology Hypertensive Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EDiabetes \u0026amp; Kidney Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EHypertension \u0026amp; Kidney Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ERenal Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ERenal Disease\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EHypertensive individuals, who cannot achieve target blood pressure (BP) levels despite being treated with triple-drug regimens, including a diuretic, are diagnosed as having resistant hypertension (rHT) [Calhoun DA et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2008], which is an increasingly common clinical problem [Egan BM et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2011]. rHT is believed to be caused by over- and chronic activation of the sympathetic nervous system. Renal sympathetic hyperactivity is influential in the maintenance and progression of hypertension, while the interruption of sympathetic nerves in the kidney has a strong impact on BP and survival. Michael B\u00f6hm, MD, Universit\u00e4tsklinikum des Saarlandes, Saarbr\u00fccken, Germany, discussed the impact of renal denervation as a treatment for hypertension.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EA better understanding of renal nerve anatomy has enabled the use of a catheter-based radio frequency approach for the ablation of nerves using a standard interventional technique. The Renal Denervation in Patients with Refractory Hypertension [Symplicity HTN-1; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00664638\u0026amp;atom=%2Fspmdc%2F12%2F16%2F32.atom\u0022\u003ENCT00664638\u003C\/a\u003E] study established the safety and proof-of-principle for catheter-based renal sympathetic denervation in patients with rHT In the study, 95% of patients experienced significant reductions in BP, which were sustained for 24 months without significant adverse events. There was no evidence of the development of tolerance or re-enervation. In the Symplicity HTN-2 [\u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00888433\u0026amp;atom=%2Fspmdc%2F12%2F16%2F32.atom\u0022\u003ENCT00888433\u003C\/a\u003E] study, the primary endpoint was change in seated office-based systolic BP (SBP). At 6 months, 41 (84%) of 49 patients who underwent renal denervation had a reduction in SBP of 10 mm Hg or more compared with 18 (35%) of 51 controls (p\u0026lt;0.0001) [Symplicity HTN-2 Investigators. \u003Cem\u003ELancet\u003C\/em\u003E 2010].\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EIn an extension of the Symplicity HTN-2 study, investigators assessed the effects of renal denervation on cardiorespiratory response to exercise. The results showed that BP during exercise was reduced, heart rate at rest decreased, and heart rate recovery improved (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Ukena C et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2011]. In addition to its known effect on BP, renal denervation has also been shown to significantly reduce left ventricular mass and improve diastolic function, which might have important prognostic implications in patients with resistant hypertension at high cardiovascular risk [Brandt MC et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2012].\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/16\/32\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Heart Rate Change During Exercise.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-868293775\u0022 data-figure-caption=\u0022Heart Rate Change During Exercise.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/16\/32\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/16\/32\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/16\/32\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13074\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-5\u0022 class=\u0022first-child\u0022\u003EHeart Rate Change During Exercise.\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003ERD=renal denervation. Reprinted from Ukena C et al. Cardiorespiratory response to exercise after renal sympathetic denervation in patients with resistant hypertension. J Am Coll Cardiol. 2011 Sep 6;58(11):1176\u201382, with permission from Elsevier.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-6\u0022\u003ELuis M. Ruilope, MD, Hospital 12 de Octubre, Madrid, Spain, discussed the prevalence, treatment, and risk factors for rHT.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EData from the National Health and Nutrition Examination Survey [NHANES] found that rHT increased from 15.9% (1988 to 2004) to 28.0% (2005 to 2008) of treated patients (p\u0026lt;0.001) [Egan BM et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2011]. However, another study found the percentage to be as low as 12.2%, of which only 7.6% was true rHT (the remaining 4.6% was \u201cwhite-coat\u201d hypertension) [de la Sierra A et al. \u003Cem\u003EHypertension\u003C\/em\u003E 2011]. Part of the problem with identifying rHT is how BP is measured. The best method for a correct diagnosis is likely 24-hour ambulatory BP monitoring (ABPM), particularly in diabetic patients [Gorostidi M et al. \u003Cem\u003EHypertens Res\u003C\/em\u003E 2011]. Twenty-four-hour ABPM can identify variations in BP levels throughout the day and eliminate the white-coat effect. High ABPM values are associated with worse prognosis in rHT patients, as well as higher incidence of cardiovascular events.\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003ErHT is almost always multifactorial in etiology. In addition to obesity and diabetes, excessive salt consumption is an important contributor, hence strategies to reduce dietary salt intake should be part of the overall treatment plan [Pimenta E et al. \u003Cem\u003EHypertension\u003C\/em\u003E 2009]. Secondary causes include obstructive sleep apnea (OSA), renal parenchymal disease, primary aldosteronism, and renal artery stenosis [Calhoun DA et al. \u003Cem\u003EHypertension\u003C\/em\u003E 2008]. Once it has been determined that the patient has truly resistant hypertension (pseudoresistance has been ruled out, lifestyle- and medication-related issues have been eliminated, and secondary causes of rHT have been excluded) a pharmacologic approach should be developed. At present the most effective treatment paradigm appears to be triple-combination drug therapy [Calhoun DA et al. \u003Cem\u003EHypertension\u003C\/em\u003E 2009]. In patients uncontrolled by triple therapy, spironolactone has been shown to be effective in lowering BP [Chapman N et al. \u003Cem\u003EHypertension\u003C\/em\u003E 2007; Alvarez-Alvarez B et al. \u003Cem\u003EJ Hypertension\u003C\/em\u003E 2010].\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003ErHT is highly prevalent and frequently accompanied by other cardiovascular risk factors. Prof. Ruilope concluded that, following failed pharmacological therapy, renal denervation should play a role in its treatment.\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EFelix Mahfoud, MD, Universit\u00e4tsklinikum des Saarlandes, Saarbr\u00fccken, Germany, discussed the topics of glucose metabolism, insulin resistance, heart failure, and OSA in relation to renal denervation.\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EIn a pilot study in patients with rHT, renal denervation reduced fasting, mean 2-hour glucose and C-peptide levels, and insulin sensitivity, in addition to significantly reducing BP (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E), suggesting that the procedure may provide protection for patients with rHT and metabolic disorders who are at high cardiovascular risk [Mahfoud F et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2011]. Studies have also shown that bilateral renal nerve ablation is associated with substantial improvement in insulin sensitivity, while reducing glomerular hyperfiltration and urinary albumin excretion [Schlaich MP et al. \u003Cem\u003EJ Hypertens\u003C\/em\u003E 2011] and improving glucose tolerance [Witkowski A et al. \u003Cem\u003EHypertension\u003C\/em\u003E 2011].\u003C\/p\u003E\u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/16\/32\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022BP Reduction After Renal Denervation.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-868293775\u0022 data-figure-caption=\u0022BP Reduction After Renal Denervation.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/16\/32\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/16\/32\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/16\/32\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13076\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n            \u003Cp id=\u0022p-12\u0022 class=\u0022first-child\u0022\u003EBP Reduction After Renal Denervation.\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReprinted from Mahfoud F et al. Effect of Renal Sympathetic Denervation on Glucose Metabolism in Patients With Resistant Hypertension: A Pilot Study. \u003Cem\u003ECirculation.\u003C\/em\u003E 2011;123:1940\u20131946, with permission from Lipincott Williams and Wilkins.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-13\u0022\u003ESympathetic activity correlates to NYHA class and heart failure, while chronic heart failure (CHF) is characterized by increased sympathetic activity, which is proportional to severity of CHF. Cardiac norepinephrine spillover increased 3-fold in mild to moderate CHF patients and 4-fold in severe CHF patients. This indicates increased amounts of transmitter available at neuroeffector junctions that precede the augmented sympathetic outflow to the kidneys and skeletal muscle found in advanced CHF. Because previous research suggests that the kidneys are a major contributor to heart failure, a study of the effects of sympathetic renal denervation in patients with CHF is in progress.\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EOSA is associated with sympathovagal imbalance, atrial fibrillation, and postapneic BP increases. Renal denervation displays antiarrhythmic effects by reducing negative tracheal pressure\u2013induced atrial effective refractory period shortening, and it inhibits postapneic BP increases associated with OSA-associated AF [Linz D et al. \u003Cem\u003EHypertension\u003C\/em\u003E 2012]. The safety of renal denervation was demonstrated in a study that showed the procedure reduced BP, renal resistive index, and the incidence of albuminuria without adversely affecting glomerular filtration rate or renal artery structure [Mahfoud F et al. \u003Cem\u003EHypertension\u003C\/em\u003E 2012].\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003EProf. Mahfoud suggested that patients with the following characteristics are suitable for renal denervation:\u003C\/p\u003E\u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n            \u003Cp id=\u0022p-16\u0022\u003ESBP \u2265160 mm Hg (\u2265150 mm Hg for type 2 diabetes patients)\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n            \u003Cp id=\u0022p-17\u0022\u003E\u22653 antihypertensive drugs in adequate dosage and combination (including diuretic)\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n            \u003Cp id=\u0022p-18\u0022\u003ECompletion of life-style modifications (eg, diet)\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n            \u003Cp id=\u0022p-19\u0022\u003EExclusion of secondary hypertension\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\n            \u003Cp id=\u0022p-20\u0022\u003EExclusion of pseudoresistance (eg, via 24-hour ABPM)\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-6\u0022\u003E\n            \u003Cp id=\u0022p-21\u0022\u003EPreserved renal function (estimated glomerular filtration rate \u226545 mL\/min\/1.73 m\u003Csup\u003E2\u003C\/sup\u003E)\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-7\u0022\u003E\n            \u003Cp id=\u0022p-22\u0022\u003EEligible renal arteries: no stenosis, no percutaneous transluminal angioplasty\/stenting\u003C\/p\u003E\n         \u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2012 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/12\/16\/32.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzn96p\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzn96p\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}