Haemodialysis patients show sympathetic hyperactivity. Hyperactivation of the sympathetic nervous system aggravates hypertension and it is related to left ventricular hypertrophy, heart failure, arrhythmias and atherogenesis. We report the first use of renal sympathetic nerve ablation for correction of uncontrolled hypertension in an end-stage renal disease patient on maintenance dialysis. We observed a progressive and sustained reduction of systemic blood pressure. Our case demonstrates the safety, the feasibility and the efficacy of this procedure. These findings suggest, however, that further clinical trials are needed into renal nerve radiofrequency ablation therapy for the treatment of hypertension and for the improvement of cardiovascular prognosis in this high-risk patient group

De Francesco,M

Di Daniele,N

Simonetti,G

Spinelli,A

Violo,L

N. Di Daniele

M. De Francesco

L. Violo

A. Spinelli

G. Simonetti

Crossref

Nephrology Dialysis Transplantation

Renal sympathetic nerve ablation for the treatment of difficult-to-control or refractory hypertension in a haemodialysis patient

DI DANIELE, NICOLA

SIMONETTI, GIOVANNI MARIA EGISTO

Nephrol Dial Transplant (2012) 27: 1689–1690doi: 10.1093/ndt/gfs044The Bench to Bedside Transition - Exceptional CaseRenal sympathetic nerve ablation for the treatment ofdifficult-to-control or refractory hypertension in a haemodialysispatientNicola Di Daniele1, Marianna De Francesco1, Leano Violo1, Alessio Spinelli2 and Giovanni Simonetti21Nephrology, Dialysis and Hypertension Division, Department of Internal Medicine, ‘Tor Vergata’ University, Rome, Italy and2Department of Diagnostic Imaging, Molecular Imaging, Interventional Radiology, ‘Tor Vergata’ University, Rome, ItalyCorrespondence and offprint requests to: Marianna De Francesco; E-mail: maridefrancesco@libero.itAbstractHaemodialysis patients show sympathetic hyperactivity.Hyperactivation of the sympathetic nervous system aggra-vates hypertension and it is related to left ventricular hyper-trophy, heart failure, arrhythmias and atherogenesis. Wereport the first use of renal sympathetic nerve ablation forcorrection of uncontrolled hypertension in an end-stagerenal disease patient on maintenance dialysis. We observeda progressive and sustained reduction of systemic bloodpressure. Our case demonstrates the safety, the feasibilityand the efficacy of this procedure. These findings suggest,however, that further clinical trials are needed into renalnerve radiofrequency ablation therapy for the treatment ofhypertension and for the improvement of cardiovascularprognosis in this high-risk patient group.Keywords: haemodialysis; renal denervation; resistant hypertension;sympathetic hyperactivityHaemodialysis patients show sympathetic hyperactivity [1].Sympathetic activation induces renal vasoconstriction andincreased renin secretion with enhanced sodium and waterreabsorption. Hyperactivation of the sympathetic nervoussystem aggravates hypertension and it is related to leftventricular hypertrophy, heart failure, arrhythmias andatherogenesis [2]. The correction of uraemia by renal trans-plantation did not result in the normalization of sym-pathetic activity, which was only abolished by bilateralnephrectomy, suggesting that sympathetic activation isdriven by the native kidney [1]. Recently, a novel andminimally invasive approach with a catheter-based radio-frequency ablation technology has aroused considerableinterest [3]. We report the first use, to our knowledge, ofrenal sympathetic nerve ablation for correction of uncon-trolled hypertension in an end-stage renal disease patient onmaintenance dialysis. A 39-year-old patient on chronichaemodialysis underwent the procedure. The cause of renalfailure was nephrosclerosis due to long-standing malignanthypertension that was resistant to pharmacological treat-ment with five different anti-hypertensive drugs. Beforethe procedure, the mean office blood pressure was 180 15/105  11 mmHg, with a heart rate of 72 beats/minute.After access via the femoral artery, a radiofrequency ab-lation catheter (Symplicity Catheter; Ardian Inc., PaloAlto, CA) was inserted into each renal artery. Six ablationswere performed within each renal artery. We observed aprogressive and sustained reduction of systemic blood pres-sure from 180  15/105  11 mmHg at baseline to 155 14/90  10 mmHg at 1 month (Figure 1). The ambulatoryblood pressure monitoring showed a decrease in systolicand diastolic average blood pressure variability (from11.35 to 10.63 mmHg at 1 month). The patient’s residualdiuresis of 500 mL daily was conserved and the dry weightof the patient was not modified with dialysis. Blood pres-sure reduction was accompanied by reduced renin andangiotensin-converting enzyme activity (from 13.12 to11.06 ng/mL/h and from 22.62 to 14.94 IU/L at 1 month).Our case report suggests that renal sympathetic denervationmay result in a substantial reduction in blood pressure inhaemodialysis patients with refractory hypertension.Fig. 1. Twenty-four-hour ambulatory blood pressure monitoring beforeand after the procedure. Systolic and diastolic blood pressure 1 month afterrenal sympathetic denervation. The Author 2012. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.For Permissions, please e-mail: journals.permissions@oup.com by guest on May 7, 2013http://ndt.oxfordjournals.org/Downloaded from Conflict of interest statement. None declared.References1. Converse RL Jr, Jacobsen TN, Toto RD et al. Sympathetic overac-tivity in patients with chronic renal failure. N Engl J Med 1992; 327:1912–19182. Blankestijn PJ. Sympathetic hyperactivity in chronic kidney disease.Nephrol Dial Transplant 2004; 19: 1354–13573. Krum H, Schlaich M, Whitbourn R et al. Catheter-based renalsympathetic denervation for resistant hypertension: a multicentresafety and proof-of-principle cohort study. Lancet 2009; 373:1275–1281Received for publication: 23.1.12; Accepted in revised form: 24.1.121690 N. Di Daniele et al. by guest on May 7, 2013http://ndt.oxfordjournals.org/Downloaded from 

English

Renal sympathetic nerve ablation for the treatment of difficult-to-control or refractory hypertension in a haemodialysis patient.

Di Daniele, N

De Francesco, M

Violo, L

Spinelli, A

Simonetti, G

Cineca Institutional Research Information System

Archivio della Ricerca - Università di Roma Tor vergata

Nephrol Dial Transplant (2012) 27: 1689–1690
doi: 10.1093/ndt/gfs044
The Bench to Bedside Transition - Exceptional Case
Renal sympathetic nerve ablation for the treatment of
difficult-to-control or refractory hypertension in a haemodialysis
patient
Nicola Di Daniele1, Marianna De Francesco1, Leano Violo1, Alessio Spinelli2 and Giovanni Simonetti2
1Nephrology, Dialysis and Hypertension Division, Department of Internal Medicine, ‘Tor Vergata’ University, Rome, Italy and
2Department of Diagnostic Imaging, Molecular Imaging, Interventional Radiology, ‘Tor Vergata’ University, Rome, Italy
Correspondence and offprint requests to: Marianna De Francesco; E-mail: maridefrancesco@libero.it
Abstract
Haemodialysis patients show sympathetic hyperactivity.
Hyperactivation of the sympathetic nervous system aggra-
vates hypertension and it is related to left ventricular hyper-
trophy, heart failure, arrhythmias and atherogenesis. We
report the first use of renal sympathetic nerve ablation for
correction of uncontrolled hypertension in an end-stage
renal disease patient on maintenance dialysis. We observed
a progressive and sustained reduction of systemic blood
pressure. Our case demonstrates the safety, the feasibility
and the efficacy of this procedure. These findings suggest,
however, that further clinical trials are needed into renal
nerve radiofrequency ablation therapy for the treatment of
hypertension and for the improvement of cardiovascular
prognosis in this high-risk patient group.
Keywords: haemodialysis; renal denervation; resistant hypertension;
sympathetic hyperactivity
Haemodialysis patients show sympathetic hyperactivity [1].
Sympathetic activation induces renal vasoconstriction and
increased renin secretion with enhanced sodium and water
reabsorption. Hyperactivation of the sympathetic nervous
system aggravates hypertension and it is related to left
ventricular hypertrophy, heart failure, arrhythmias and
atherogenesis [2]. The correction of uraemia by renal trans-
plantation did not result in the normalization of sym-
pathetic activity, which was only abolished by bilateral
nephrectomy, suggesting that sympathetic activation is
driven by the native kidney [1]. Recently, a novel and
minimally invasive approach with a catheter-based radio-
frequency ablation technology has aroused considerable
interest [3]. We report the first use, to our knowledge, of
renal sympathetic nerve ablation for correction of uncon-
trolled hypertension in an end-stage renal disease patient on
maintenance dialysis. A 39-year-old patient on chronic
haemodialysis underwent the procedure. The cause of renal
failure was nephrosclerosis due to long-standing malignant
hypertension that was resistant to pharmacological treat-
ment with five different anti-hypertensive drugs. Before
the procedure, the mean office blood pressure was 180 
15/105  11 mmHg, with a heart rate of 72 beats/minute.
After access via the femoral artery, a radiofrequency ab-
lation catheter (Symplicity Catheter; Ardian Inc., Palo
Alto, CA) was inserted into each renal artery. Six ablations
were performed within each renal artery. We observed a
progressive and sustained reduction of systemic blood pres-
sure from 180  15/105  11 mmHg at baseline to 155 
14/90  10 mmHg at 1 month (Figure 1). The ambulatory
blood pressure monitoring showed a decrease in systolic
and diastolic average blood pressure variability (from
11.35 to 10.63 mmHg at 1 month). The patient’s residual
diuresis of 500 mL daily was conserved and the dry weight
of the patient was not modified with dialysis. Blood pres-
sure reduction was accompanied by reduced renin and
angiotensin-converting enzyme activity (from 13.12 to
11.06 ng/mL/h and from 22.62 to 14.94 IU/L at 1 month).
Our case report suggests that renal sympathetic denervation
may result in a substantial reduction in blood pressure in
haemodialysis patients with refractory hypertension.
Fig. 1. Twenty-four-hour ambulatory blood pressure monitoring before
and after the procedure. Systolic and diastolic blood pressure 1 month after
renal sympathetic denervation.
 The Author 2012. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.
For Permissions, please e-mail: journals.permissions@oup.com
 by guest on M
ay 7, 2013
http://ndt.oxfordjournals.org/
D
ow
nloaded from
 
Conflict of interest statement. None declared.
References
1. Converse RL Jr, Jacobsen TN, Toto RD et al. Sympathetic overac-
tivity in patients with chronic renal failure. N Engl J Med 1992; 327:
1912–1918
2. Blankestijn PJ. Sympathetic hyperactivity in chronic kidney disease.
Nephrol Dial Transplant 2004; 19: 1354–1357
3. Krum H, Schlaich M, Whitbourn R et al. Catheter-based renal
sympathetic denervation for resistant hypertension: a multicentre
safety and proof-of-principle cohort study. Lancet 2009; 373:
1275–1281
Received for publication: 23.1.12; Accepted in revised form: 24.1.12
1690 N. Di Daniele et al.
 by guest on M
ay 7, 2013
http://ndt.oxfordjournals.org/
D
ow
nloaded from
 


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Renal sympathetic nerve ablation for the treatment of difficult-to-control or refractory hypertension in a haemodialysis patient.

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