Miguel Luis Graciano

Effects of renal denervation with a standard irrigated cardiac ablation catheter on blood pressure and renal function in patients with chronic kidney disease and resistant hypertension

AIMS Evaluation of the safety and efficacy of renal denervation with a standard irrigated cardiac ablation catheter (SICAC) in chronic kidney disease (CKD) patients with refractory hypertension. METHODS AND RESULTS Twenty-four patients were included and treated with a SICAC. Denervation was performed by a single operator following the standard technique. Patients included with CKD were on stages 2 (n = 16), 3 (n = 4), and 4 (n = 4). Data were obtained at baseline and monthly until 180th day of follow-up. Baseline values of blood pressure (mean ± SD) were 186 ± 19 mmHg/108 ± 13 mmHg in the office, and 151 ± 18 mmHg/92 ± 11 mmHg by 24 h ambulatory blood pressure monitoring (ABPM). Office blood pressure values at 180th day after the procedure were 135 ± 13 mmHg/88 ± 7 mmHg (P < 0.0001, for both comparisons). The mean ABPM decreased to 132 ± 15 mmHg/85 ± 11 mmHg at the 180th day after the procedure (P < 0.0001 for systolic and P = 0.0015 for diastolic). Estimated glomerular filtration (mean ± SD) increased from baseline (64.4 ± 23.9 mL/min/1.73 m(2)) to the 180th day (85.4 ± 34.9 mL/min/1.73 m(2), P < 0.0001) of follow-up. The median urine albumin:creatinine ratio decreased from baseline (48.5, IQR: 35.8-157.2 mg/g) to the 180th day after ablation (ACR = 15.7, IQR: 10.3-34.2 mg/g, P = 0.0017). No major complications were seen. CONCLUSION The procedure using SICAC seemed to be feasible, effective, and safe resulting in a better control of BP, a short-term increase in estimated glomerular filtration rate, and reduced albuminuria. Although encouraging, our data are preliminary and need to be validated in the long term.

Long‐Term Effects of Renal Sympathetic Denervation on Hypertensive Patients With Mild to Moderate Chronic Kidney Disease

Thirty patients who underwent percutaneous renal denervation, which was performed by a single operator following the standard technique, were enrolled in this study. Patients with chronic kidney disease (CKD) stage 2 (n=19), 3 (n=6), and 4 (n=5) were included. Data were obtained at baseline and at monthly intervals for the first 6 months. At 7 months, follow‐up data were collected bimonthly until month 12, after which data were collected on a quarterly basis. Baseline blood pressure values (mean±standard deviation) were 185±18/107±13 mm Hg in the office and 152±17/93±11 mm Hg through 24‐hour ambulatory blood pressure monitoring (ABPM). Three patients with stage 4 CKD required chronic renal replacement therapy (one at the 13‐month follow‐up and two at the 14‐month follow‐up) after episodes of acute renal injury; their follow‐up was subsequently discontinued. The office blood pressure values at the 24‐month follow‐up were 131±15/87±9 mm Hg (P<.0001, for both comparisons); the corresponding ABPM values were 132±14/84±12 mm Hg (P<.0001, for both comparisons). The mean estimated glomerular filtration rate increased from 61.9±23.9 mL/min/1.73 m2 to 88.0±39.8 mL/min/1.73 m2 (P<.0001). The urine albumin:creatinine ratio decreased from 99.8 mg/g (interquartile range, 38.0–192.1) to 11.0 mg/g (interquartile range, 4.1–28.1; P<.0001 mg/g). At the end of the follow‐up period, 21 patients (70% of the initial sample) were no longer classified as having CKD.

Renal Sympathetic Denervation in Patients With Hypertension and Chronic Kidney Disease: Does Improvement in Renal Function Follow Blood Pressure Control?

Twenty‐seven patients with resistant hypertension and chronic kidney disease were treated by renal sympathetic denervation (RSD) and followed for 12 months. Patients were retrospectively divided into controlled and uncontrolled blood pressure (BP) groups. Increases in mean estimated glomerular filtration rate (eGFR) were found at months 1, 3, 6, and 12 in the controlled group (P<.0001, for every time point). The mean change in eGFR after 12 months was 18.54±8.15 mL/min/1.73m2 higher in the controlled group (P=.0318). In patients in the controlled group with baseline eGFR <45 mL/min/1.73 m2, responders (with an increase in eGFR >6.2%) corresponded to 50% at 6 months and 83% at 12 months. In the patients with baseline eGFR ≥45 mL/min/1.73 m2, all patients were labeled as responders at months 6 and 12. Median albumin:creatinine ratio after 12 months was lower than baseline only in the controlled group (P=.0003). Our results suggest that patients with this profile who reached BP control by RSD also experienced a significant improvement in renal function.

Proof of concept study: Improvement of echocardiographic parameters after renal sympathetic denervation in CKD refractory hypertensive patients.

AIM Evaluation of the effectiveness of the renal sympathetic denervation (RSD) in reducing lesions of target organs such as the heart and kidneys, in resistant hypertensive CKD patients. METHODS AND RESULTS Forty-five patients were included and treated with an ablation catheter with open irrigated tip. RSD was performed by a single operator following the standard technique. Patients included with CKD were on stages 2 (n=22), 3 (n=16), and 4 (n=7). Data were obtained at baseline and monthly until the 6th month of follow-up. Twenty-six out of the 45 patients had LVH and nineteen did not present LVH. The LV mass index decreased from 123.70±38.44g/m(2) at baseline to 106.50±31.88g/m(2) at the 6th month after RSD, P<0.0001. The end-diastolic left ventricular internal dimension (LVIDd) reduced from 53.02±6.59mm at baseline to 51.11±5.85mm 6months post procedure, P<0.0001. The left ventricular end-diastolic posterior wall thickness (PWTd) showed a reduction from 10.58±1.39mm at baseline to 9.82±1.15mm at the 6th month of follow-up, P<0.0001. The end-diastolic interventricular septum thickness (IVSTd) also decreased from 10.58±1.39mm at baseline to 9.82±1.15mm 6months post procedure, P<0.0001. The left ventricular ejection fraction (LVEF) improved from 58.90±10.48% at baseline to 62.24±10.50% at the 6th month of follow-up, P<0.0001. When the ∆ between baseline and the 6th month post RSD in LVH patients and non LVH patients were compared to the same parameters no significant difference was found. CONCLUSIONS The RSD seemed to be feasible, effective, and safe resulting in an improvement of echocardiographic parameters in LVH and non LVH CKD refractory hypertensive patients.

Acute effect of renal sympathetic denervation on blood pressure in refractory hypertensive patients with chronic kidney disease

a Renal Division, Department of Medicine, Universidade Federal Fluminense, Niteroi, RJ, Brazil b Hospital Regional Darcy Vargas, Rio Bonito, RJ, Brazil c Department of Cardiology, Shanghai First Peoples Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China d Fellowship of European Heart Rhythm Association/European Society of Cardiology, Department of Cardiology, Elisabethinen University Teaching Hospital Linz, Linz, Austria e Abteilung Elektrophysiologie, Herzzentrum, Universitat Leipzig, Leipzig, Sachsen, Germany

Effects of renal sympathetic denervation in left ventricular hypertrophy in CKD refractory hypertensive patients

Article history: Received 26 July 2015 Received in revised form 22 August 2015 Accepted 26 August 2015 Available online 29 August 2015 formed consent was obtained from every patient. In the period from June 2011 to December 2012, thirty consecutive patients underwent RSD. All of them had resistant hypertension and CKD (stages 2, 3 and 4), as shown in Table 1. They underwent laboratory tests and assessment of renal function at baseline and 24 h post-procedure, before discharge. The procedures were performed in the catheterization laboratory with direct visualization using fluoroscopy and radiopaque contrast. In

Troponin I serum levels predict the need of dialysis in incident sepsis patients with acute kidney injury in the intensive care unit

INTRODUCTION Sepsis, an extremely prevalent condition in the intensive care unit, is usually associated with organ dysfunction, which can affect heart and kidney. OBJECTIVE To determine whether the cardiac dysfunction and the Troponin I forecast the occurrence of acute renal failure in sepsis. METHODS Cardiac dysfunction was assessed by echocardiography and by the serum troponin I levels, and renal impairment by AKIN criteria and the need of dialysis. Twenty-nine patients with incident sepsis without previous cardiac or renal dysfunction were enrolled. RESULTS AND DISCUSSION Patients averaged 75.3 ± 17.3 years old and 55% were male. Median APACHE II severity score at ICU admission was 16 (9.7 - 24.2) and mortality rate in 30 days was 45%. On the fifth day, 59% had ventricular dysfunction. Troponin serum levels on day 1 in the affected patients were 1.02 ± 0.6 ng/mL compared with 0.23 ± 0.18 ng/mL in patients without heart dysfunction (p = 0.01). Eighteen out of 29 patients (62%) underwent renal replacement therapy (RRT) and the percent of patients with ventricular dysfunction who required dialysis was higher (94% vs. 16%, p = 0.0001). Values of troponin at day 1 were used to develop a ROC curve to determine their ability to predict the need of dialysis. The area under the curve was 0.89 and the cutoff value was 0.4 ng/mL. CONCLUSION We found that an elevation in serum troponin levels, while guarding a relationship with ventricular dysfunction, can be a precious tool to predict the need for dialysis in sepsis patients.

Improvement of the renal function after renal sympathetic denervation in refractory hypertensive patients with chronic kidney disease: Possible predictors

a Renal Division, Department of Medicine, Universidade Federal Fluminense, Niterói, RJ, Brazil b Hospital Regional Darcy Vargas, Rio Bonito, RJ, Brazil c Department of Cardiology, Shanghai First Peoples Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China d Fellowship of European Heart Rhythm Association/European Society of Cardiology, Department of Cardiology, Elisabethinen University Teaching Hospital Linz, Linz, Austria e Abteilung Elektrophysiologie, Herzzentrum, Universität Leipzig, Leipzig, Sachsen, Germany

CKD after AKI: time to be alert

Ao longo da decada, a epidemiologia de lesoes renais agudas (IRA) vem evoluindo de forma constante, de uma sindrome associada a perfusao renal em pacientes mais jovens ate o estagio atual de comprometimento renal comumente desencadeado pela inflamacao em idosos. Atualmente, o paciente tipico com IRA abriga multiplas morbidades e reduzida reserva funcional renal conferida por varios e diferentes agravos cronicos, como diabetes, hipertensao, idade avancada e isquemia. […] DRC apos IRA: momento para estar alerta

Proof of concept study: Improvement of echocardiographic parameters after renal sympathetic denervation in CKD refractory hypertensive patients - diastolic function

Aim: We evaluated the effectiveness of the renal sympathetic denervation (RSD) in diastolic heat and renal functions, in resistant hypertensive CKD patients. Methods and results: Data were obtained at baseline and monthly until 6th month of follow-up. Twenty-six out of the 45 patients had LVH and nineteen did not present LVH. The LV mass index decreased from 123.70 ± 38.44 g/m2 at baseline to 106.50 ± 31.88 g/m2 at the 6th month after RSD, P<0.0001. The comparison between baseline and the 6th month post RSD showed that the mitral valve E deceleration time shortened from 242.40 ± 45.11 ms to 214.50 ± 36.40 ms (P<0.0001), and a significant reduction in the isovolumic relaxation time (IVRT) was noted from 126.10 ± 26.56 ms to 107.80 ± 24.53 ms (P<0.0001). Tissue Doppler imaging revealed a significant reduction in the ratio of mitral inflow velocity to annular relaxation velocity (lateral E/e’), a marker of LV diastolic filling pressure, significantly decreased from 9.49 ± 2.57 at baseline to 6.88 ± 1.96 at the 6th month post procedure (P<0.0001). When the variation between baseline and the 6th month post RSD in LVH patients and non LVH patients were compared to the same parameters: mitral valve E deceleration time (-29.65 ± 15.80 ms and -25.53 ± 20.04 ms, respectively, P=0.4439), the IVRT (-20.00 ± 13.78 ms and -16.05 ± 12.65 ms, respectively, P=0.3316), and mitral valve lateral E/e’ ratio (-2.82 ± 1.21 and -2.32 ± 1.27, respectively, P=0.1900) no significant difference was found. Conclusion: The RSD showed an improvement of diastolic echocardiographic parameters in LVH and non LVH CKD refractory hypertensive patients. Correspondence to: Jocemir Ronaldo Lugon, Centro de Diálise, Hospital Universitário Antônio Pedro, Rua Marquês do Paraná 303, 2° Andar, Niterói, RJ 24033-900, Brazil, Tel: +55 2126299169; Fax: +55 2126299260; E-mail: jocerl@huap.uff.br