Margreet F. Sanders

Impact of Medication Adherence on the Effect of Renal DenervationNovelty and Significance: The SYMPATHY Trial

Randomized trials of catheter-based renal denervation (RDN) as therapy for resistant hypertension showed conflicting results in blood pressure (BP) lowering effect. Adherence to medication is modest in this patient group and may importantly drive these conflicting results. SYMPATHY is a prospective open label multicenter trial in Dutch patients with resistant hypertension. Primary outcome was change in daytime systolic ambulatory BP at 6 months. Patients were randomly assigned to RDN on top of usual care. Adherence to BP lowering drugs was assessed at baseline and follow-up, using blood samples drawn synchronously with BP measurements. Patients and physicians were unaware of the adherence assessment. Primary analyses showed a mean difference between RDN (n=95) and control (n=44) in changes in daytime systolic ambulatory BP after 6 months of 2.0 mm Hg (95% confidence interval, −6.1 to 10.2 mm Hg) in favor of control. In 80% of patients, fewer medications were detected than prescribed and adherence changed during follow-up in 31%. In those with stable adherence during follow-up, mean difference between RDN and control for daytime systolic ambulatory BP was −3.3 mm Hg (−13.7 to 7.2 mm Hg) in favor of RDN. RDN as therapy for resistant hypertension was not superior to usual care. Objective assessment of medication use shows that medication adherence is extremely poor, when patients are unaware of monitoring. Changes over time in adherence are common and affect treatment estimates considerably. Objective measurement of medication adherence during follow-up is strongly recommended in randomized trials. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01850901.

Renal safety of catheter-based renal denervation: systematic review and meta-analysis

Background: Catheter‐based renal denervation (RDN) is a possible treatment to lower blood pressure. The invasive nature of RDN and the use of contrast agents raise concerns about potential consequent kidney damage. Our objective was to determine the change in renal function after RDN by performing a systematic review on hypertensive patients treated with RDN. Methods: A systematic search was performed in the Embase and MEDLINE databases to identify studies reporting on the effects of catheter‐based RDN on renal outcome. Studies published between January 2009 and May 2016, irrespective of study design, device used or indication for treatment were included. We performed random effects meta‐analyses on the change in estimated glomerular filtration rate (eGFR), serum creatinine, serum cystatin C and albumin:creatinine ratio after RDN. We only extracted and meta‐analysed data from patients treated with RDN. Results: From 1034 citations, 52 studies (38 cohort studies, 4 non‐randomized comparative studies and 10 randomized controlled trials) reporting on 56 RDN cohorts were included in meta‐analyses and another 14 studies in a qualitative review. Of these 56 cohorts, 48 were specifically eligible for determining the change in eGFR after RDN, totaling 2381 patients. There was no statistically significant change in eGFR after a mean follow‐up time of 9.1 ± 7.0 months [0.64 mL/min/1.73 m2 (95% confidence interval −0.47 to 1.76), P = 0.26]. The pooled mean change in serum creatinine and the results of the qualitative review further supported these findings. Conclusions: Based on meta‐analyses of 52 studies and a qualitative review of an additional 14 studies, reporting on 2898 patients in total, we conclude that renal function does not significantly change up to at least 9 months after RDN.

Renal denervation in a real life setting : A gradual decrease in home blood pressure

Objectives To investigate the blood pressure dynamics after renal denervation through monthly home blood pressure measurements throughout the first 12 months. Methods A cohort of 70 patients performed highly standardized monthly home blood pressure monitoring during the first year after denervation according to the European Society of Hypertension guidelines. At baseline and 12 months follow-up, office and ambulatory blood pressure as well as routine physical and laboratory assessment was performed. Results Home blood pressure decreased with a rate of 0.53 mmHg/month (95% CI 0.20 to 0.86) systolic and 0.26 mmHg/month (95% CI 0.08 to 0.44) diastolic throughout 12 months of follow-up, while the use of antihypertensive medication remained stable (+0.03 daily defined doses/month, 95% CI -0.01 to 0.08). On average, a 12 month reduction of 8.1 mmHg (95% CI 4.2 to 12.0) was achieved in home systolic blood pressure, 9.3 mmHg (95% CI -14.2 to -4.4) as measured by 24-hour ambulatory blood pressure monitoring and 15.9 mmHg (95% CI -23.8 to -7.9) on office measurements. Conclusion Blood pressure reduction after renal denervation occurs as a gradual decrease that extends to at least one-year follow-up. Home monitoring seems a suitable alternative for ambulatory blood pressure monitoring after renal denervation.

Chronic Kidney Disease As a Potential Indication for Renal Denervation

Renal denervation is being used as a blood pressure lowering therapy for patients with apparent treatment resistant hypertension. However, this population does not represent a distinct disease condition in which benefit is predictable. In fact, the wide range in effectiveness of renal denervation could be a consequence of this heterogeneous pathogenesis of hypertension. Since renal denervation aims at disrupting sympathetic nerves surrounding the renal arteries, it seems obvious to focus on patients with increased afferent and/or efferent renal sympathetic nerve activity. In this review will be argued, from both a pathophysiological and a clinical point of view, that chronic kidney disease is particularly suited to renal denervation.

Salt intake and blood pressure response to percutaneous renal denervation in resistant hypertension.

The effect of lowering sympathetic nerve activity by renal denervation (RDN) is highly variable. With the exception of office systolic blood pressure (BP), predictors of the BP‐lowering effect have not been identified. Because dietary sodium intake influences sympathetic drive, and, conversely, sympathetic activity influences salt sensitivity in hypertension, we investigated 24‐hour urinary sodium excretion in participants of the SYMPATHY trial. SYMPATHY investigated RDN in patients with resistant hypertension. Both 24‐hour ambulatory and office BP measurements were end points. No relationship was found for baseline sodium excretion and change in BP 6 months after RDN in multivariable‐adjusted regression analysis. Change in the salt intake–measured BP relationships at 6 months vs baseline was used as a measure for salt sensitivity. BP was 8 mm Hg lower with similar salt intake after RDN, suggesting a decrease in salt sensitivity. However, the change was similar in the control group, and thus not attributable to RDN.

[OP.7D.03] RENAL DENERVATION IN HYPERTENSIVE PATIENTS NOT ON BLOOD PRESSURE LOWERING DRUGS.

Objective: Studies on the blood pressure lowering effect of renal denervation (RDN) in resistant hypertensive patients have produced conflicting results. Change in medication usage during the studies may be responsible for this inconsistency. To eliminate the effect of medication usage on blood pressure we focused on unmedicated hypertensive patients who underwent RDN. Design and method: Our study reports on a cohort of patients who were not on blood pressure lowering drugs at baseline and during follow-up from eight tertiary centers. Data of patients were used when they were treated with RDN and had a baseline office systolic blood pressure (SBP) of at least 140 mmHg and/or 24-hour ambulatory SBP of at least 130 mmHg. Our primary outcome was defined as change in office and 24-hour SBP at 12 months after RDN, compared to baseline. Results: Fifty-three patients were included. There were three different reasons for not using blood pressure lowering drugs: 1) documented intolerance or allergic reaction (57%); 2) temporary cessation of medication for study purposes (28%); and 3) reluctance to take antihypertensive drugs (15%). Mean change in 24-hour SBP was −5.7 mmHg (95% confidence interval [CI] −11.0 to −0.4; P = 0.04). Mean change in office SBP was −13.1 mmHg (95% CI −20.4 to −5.7; P = 0.001). Figure 1 represents individual changes in blood pressure after RDN. No changes were observed in other variables, such as eGFR, body–mass-index and urinary sodium excretion. Conclusions: This explorative study in hypertensive patients, who were not on blood pressure lowering medication, suggests that at least in some patients RDN lowers blood pressure. Figure. No caption available.