肾脏去神经化在心房颤动治疗中的作用

心房颤动是临床最常见的心律失常,发病率随年龄逐渐增加,且明显增加心功能不全及血栓栓塞的发生率,严重威胁着大众健康。射频消融是心房颤动治疗的有效手段之一,但仍存在复发率高等问题。众多研究证实经皮肾脏去神经化除能够治疗顽固性高血压外,还有治疗心房颤动的潜在作用,现对肾脏去神经化在心房颤动治疗中的作用进行综述。     

肾脏神经射频消融与心脏代谢综合征的研究进展

越来越多的研究证实,肾脏去交感神经化治疗可以降低顽固性高血压病患者的血压水平.顽固性高血压病患者常常伴随着一系列代谢障碍性疾病,如胰岛素抵抗、糖耐量异常及糖尿病等,构成了所谓的心脏代谢综合征.新近研究探讨了肾脏神经射频消融术治疗顽固性高血压病患者过程中,肾脏去交感神经化对心脏代谢综合征的影响.现就肾脏神经射频消融与心脏代谢综合征的研究进展做一综述.     

经导管射频消融去肾脏交感神经术治疗难治性高血压研究现状

经导管射频消融去肾脏交感神经术是一种治疗难治性高血压的新兴非药物手段,作为一种微创手术,可以选择性消融肾交感神经纤维,阻断中枢交感神经和肾脏之间神经冲动的传递,从而达到控制血压的目的。目前关于经导管射频消融去肾脏交感神经术治疗难治性高血压的研究较多,但具有一定的争议性,现就经导管射频消融去肾脏交感神经术治疗高血压开展的有关研究现状做一综述。     

高血压病肾脏损害的诊断与防治

高血压病 (hypertensivedisease)又称为原发性高血压(primaryhypertension或essentialhypertension) ,是一种以血压升高为主要临床表现而病因尚未明确的独立性疾病 ,占所有高血压患者的 90 %以上。目前认为高血压病是在一定的遗传改变基础上 ,由于多种后天因素的作用导致正常血压调节机制失平衡所引起[1 5] 。高血压病的发病与肾脏的关系是十分密切的。肾脏既是血压调节的重要器官 ,同时又是高血压损害的主要靶器官之一。一方面 ,肾脏通过改变对水钠代谢的调节以及分泌加压和降压物质 ,从多方面影响血压。其中肾脏对血容量的调节以及对肾素…     

去肾脏交感神经支配术治疗高血压研究进展

交感神经系统激活在高血压发病中起着重要作用，故去除交感神经应是治疗高血压的有效手段。近年来，高选择性去肾脏交感神经支配术发展迅速，并有大量研究评估其有效性及安全性。本文将综述去肾脏交感神经支配术治疗高血压的相关研究进展。     

神经源性直立性低血压患者仰卧位高血压治疗的科学声明——美国自主神经学会、欧洲自主神经学会联合会和欧洲高血压学会

仰卧位高血压常见于自主神经功能衰竭所致的神经源性直立性低血压患者.仰卧位高血压促进夜间钠排泄,促进直立性低血压的形成,从而影响患者的生活质量.原发性高血压的相关研究以及自主神经功能衰竭相关的小规模研究均表明,仰卧位高血压患者可能更易患心血管疾病和肾脏疾病.上述研究为治疗仰卧位高血压提供了理论依据.然而,仰卧位高血压的治...     

肾脏神经与充血性心力衰竭的研究进展

心脏和肾脏通过血流动力学和神经体液机制相互影响,从而维持血液循环的稳定,其中肾脏交感神经是非常重要的环节,但是在充血性心力衰竭（简称心衰）时,这种正常的调节机制就变得不恰当。肾脏交感神经在充血性心衰中被激活,肾脏交感传入神经的激活,反馈性的增加中枢交感神经系统张力,从而升高外周血管阻力、促进血管及左室重构;肾脏交感传出神经激活,不仅降低肾血流、减少水钠排泄,激活了肾素-血管紧张素系统,从而促进心肌及心脏神经系统重构,加重心肾功能不全。因此,肾交感神经的活性增加预示着充血性心衰患者生存率降低。在心衰的动物模型中,外科手术去除肾脏神经（renal denervation,RD）已经显示了改善心室功能及水钠储留的作用。随着导管技术的不断发展,经肾动脉射频消融RD技术已经有望临床应用于治疗充血性心衰。     

原发性高血压及其继发肾脏损害机理的研究进展

以氧化应激(oxidative stress,OS)为核心的氧化自由基理论是目前生物医学界研究的热点。临床和动物实验均证明OS与原发性高血压呈密切的正相关。肾脏对慢性血压的调控及原发性高血压的发生起主导作用。盐敏感高血压具有显著的肾损害易感性,以盐敏感高血压动物模型对肾脏OS、肾脏损害及高血压之间关系的研究提示:肾脏OS参与了高血压继发性肾损害的发生及高血压的恶化过程。该发现突破了长期以来对此类疾病机理的传统认识,为将来可能的新的治疗措施提供了依据。     

高血压患者血浆神经降压素含量的变化

实验采用放射免疫分析法，测定12例正常人和20例高血压患者血浆中神经降压素的含量。结果表明原发性高血压和肾性高血压患者血浆中神经降压素的含量皆比正常人显著减少。提示血浆中神经降压素含量的减少，可能与血压高有关。     

从多巴胺受体的研究成果看高血压治疗的新对策

肾脏是人体负责钠排泄的重要器官,近年研究发现肾脏的利尿、排钠作用受到多巴胺的控制。所有多巴胺受体亚型均直接或间接参与血压调节和肾脏尿钠排泄。本文旨在探讨多巴胺受体在原发性高血压发生中的作用,以及多巴胺与其相关调节因子在原发性高血压防治方面的应用前景。     

The Future of Renal Denervation in Resistant Hypertension

Resistant hypertension, defined as inadequate blood pressure control despite three or more antihypertensive medications at maximally tolerated doses, is strongly linked to increased cardiovascular morbidity and mortality. Increased renal afferent and efferent sympathetic activity carried by nerves which arborize the adventitia of the renal arteries, appears to be central to the pathobiology of resistant hypertension. Historical experience indicates that surgical denervation and/or sympathectomy often dramatically reduced blood pressure in patients with malignant hypertension. Catheter-based radio-frequency renal denervation was developed in the past decade as a percutaneous adaptation of surgical denervation. Percutaneous renal denervation using a variety of systems has demonstrated to date, in non-randomized and unblinded studies, dramatic reductions in office-based blood pressure, but more modest impact on ambulatory blood pressure. The only single, appropriately powered, blinded, sham-controlled study of renal denervation conducted to date, however, failed to meet its primary endpoint, casting doubt on the value of the therapy. Ancillary benefits of renal denervation have been described in such conditions as diabetes mellitus, heart failure, and sleep apnea but require further study. While renal denervation is already widely available outside of the USA for commercial use, its utility in resistant hypertension must be vetted by further rigorous investigation before its use can be routinely recommended.     

Renal Sympathetic Denervation for Treatment of Hypertension

Sympathetic nervous system activation of the heart, kidney and peripheral vasculature increases cardiac output, fluid retention and vascular resistance and plays an important role in acute and chronic BP elevation. Renal sympathetic denervation via a percutaneous radiofrequency catheter based approach is a safe and effective procedure that lowers BP in patients with resistant hypertension. Exploratory studies in patients with resistant hypertension and a variety of comorbidities, including insulin resistance/metabolic syndrome, obstructive sleep apnea and the polycystic ovary syndrome, have shown benefit of renal denervation in attenuating the severity of the comorbid conditions, as well as reducing BP. However, more studies are needed to further address the long term effects of renal denervation and its safety and effectiveness in other disease states such as congestive heart failure.     

肾动脉交感神经射频消融术器械相关研究进展

肾动脉交感神经射频消融术具有显著的降压效果和良好的安全性,为顽固性高血压治疗提供了一种新方法。近年来,肾动脉交感神经射频消融术的射频消融装置层出不穷,各具特色,现将5种常见的肾动脉交感神经射频消融术器械及其临床研究进行综述。     

Renal sympathetic nervous system and the effects of denervation on renal arteries

Resistant hypertension is associated with chronic activation of the sympathetic nervous system resulting in various comorbidities. The prevalence of resistant hypertension is often under estimated due to various reasons. Activation of sympathetic nervous system at the renal-as well as systemic-level contributes to the increased level of catecholamines and resulting increase in the blood pressure. This increased activity was demonstrated by increased muscle sympathetic nerve activity and renal and total body noradrenaline spillover. Apart from the hypertension, it is hypothesized to be associated with insulin resistance, congestive heart failure and obstructive sleep apnea. Renal denervation is a novel procedure where the sympathetic afferent and efferent activity is reduced by various techniques and has been used successfully to treat drug-resistant hypertension improvement of various metabolic derangements.Renal denervation has the unique advantage of offering the denervation at the renal level, thus mitigating the systemic side effects. Renal denervation can be done by various techniques including radiofrequency ablation, ultrasound guided ablation and chemical ablation. Various trials evaluated the role of renal denervation in the management of resistant hypertension and have found promising results. More studies are underway to evaluate the role of renal denervation in patients presenting with resistant hypertension in different scenarios. Appropriate patient selection might be the key in determining the effectiveness of the procedure.     

Renal Nerves in the Maintenance of Hypertension: A Potential Therapeutic Target

Renal sympathetic efferent and afferent nerves, which lie within and immediately adjacent to the wall of the renal arteries, contribute to the maintenance of hypertension. Because the causative factors of hypertension change over time, denervation of both efferent and afferent renal nerves should result in long-term attenuation of hypertension. The importance of the renal nerves in hypertensive patients can now be defined with the novel development of percutaneous, minimally invasive renal denervation from within the renal artery using radiofrequency energy as a therapeutic strategy. Studies thus far show that catheter-based renal denervation in patients with resistant essential hypertension lowers systolic blood pressure 27 mm Hg by 12 months, with the estimated glomerular filtration rate remaining stable. The decrease in arterial pressure after renal denervation is associated with decreased peripheral sympathetic nervous system activity, suggesting that the kidney is a source of significant central sympathetic outflow via afferent renal nerve activity.     

Controversies in Hypertension IV: Renal Denervation

Renal denervation is not a cure for hypertension. Although more recent sham-controlled trials were positive, a significant minority of patients in each trial were unresponsive. The optimal patient or patients need to be defined. Combined systolic/diastolic hypertension appears more responsive than isolated systolic hypertension. It remains uncertain whether patients with comorbidities associated with higher adrenergic tone should be targeted, including obesity, diabetes, sleep apnea, and chronic kidney disease. No biomarker can adequately predict response. A key to a successful response is the adequacy of denervation, which currently cannot be assessed in real time. It is uncertain what is the optimal denervation methodology: radiofrequency, ultrasound, or ethanol injection. Radiofrequency requires targeting the distal main renal artery plus major branches and accessory arteries. Although denervation appears to be safe, conclusive data on quality of life, improved target organ damage, and reduced cardiovascular events/mortality are required before denervation can be generally recommended.     

Renal denervation for resistant hypertension: no

In recent years, catheter-based radiofrequency denervation of the renal arteries (RDN) has emerged as a potential treatment for resistant hypertension. Though initial non-randomized and randomized small studies demonstrate large reductions in office blood pressure, RDN superiority to conventional treatment is not confirmed either by randomized controlled trials or by large international registries. Increasing evidence supports the hypothesis that a rational pharmacological therapeutic scheme is equally or more effective; this approach, together with an intervention aimed at increasing patient’s compliance with treatment, might solve most of the cases of refractory hypertension. Thus, based on current evidence, renal denervation should not be routinely used to treat resistant hypertension. Though the possibility that RDN might be useful in other subsets of hypertensive patients exists, it has never been proven. Thus, its use should be limited to extreme situations, when all other possible treatments have failed.     

Renal Denervation for Hypertension

Hypertension is the leading cause of mortality worldwide. Effective therapies are needed for resistant hypertension, a common condition characterized by inadequate blood pressure control despite 3 or more medications, which is associated with increased cardiovascular mortality. Percutaneous catheter-based renal denervation is a promising new treatment offering the potential to improve blood pressure control, reduce cardiovascular risk, and target end-organ damage in patients with resistant hypertension. Initial studies have demonstrated procedural safety and effectiveness in blood pressure reduction up to 2 years after procedure. Large randomized control trials are necessary and currently underway to define further the role of renal denervation and long-term consequences in the treatment of resistant hypertension.     

Renal denervation in a patient with prior renal artery stenting

This is a case report of a 69‐year‐old female with treatment‐resistant severe arterial hypertension despite prior successful percutaneous intervention to both renal arteries for significant renal artery stenoses (stenting of the right and balloon angioplasty of the left renal artery). The office blood pressure was 221/108 mm Hg at baseline. Secondary hypertension was ruled out and catheter‐based renal denervation performed (distal to the stent in the right renal artery and in the usual fashion in the left renal artery) without complications. The office blood pressure decreased at 1‐ and 3‐month follow‐up to 185/93 mm Hg and 182/95 mm Hg, respectively. This case illustrates the feasibility and potential efficacy of catheter‐based renal denervation in patients with a renal artery stent, an important finding as persistent hypertension is common in patients despite successful renal artery stenting and currently available trials examining renal denervation have excluded patients with prior renal artery stents. © 2012 Wiley Periodicals, Inc.     

Renal Denervation: a Field in Flux

SYMPLICITY HTN-3 was a pivotal moment for renal denervation as a treatment option for resistant hypertension. Prior unblinded studies were called into question given the negative results of the first sham-controlled trial of renal denervation. Reevaluation of the renal denervation procedure demonstrated that a more precise approach was needed to adequately denervate the kidney. This new approach has been implemented in two ongoing clinical trials, one on and one off medications to assess the new procedure’s efficacy and safety. These and other ongoing trials will be discussed in the context of older studies in this field. We focus on novel findings published following the release of SYMPLICITY HTN-3 data in early 2014 and look to the future of renal denervation in the treatment of primary hypertension.