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Boschetti E, Alrashdi Y, Schillaci G. Renal denervation for resistant hypertension: yes. Intern Emerg Med 2016; 11:491-3. [PMID: 26970989 DOI: 10.1007/s11739-016-1429-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 02/25/2016] [Indexed: 11/29/2022]
Abstract
Sympathetic overactivity may have a role in triggering and maintaining resistant hypertension, and catheter-based renal denervation (RDN) has emerged as a promising treatment in refractory hypertension. Recently, the results of the Symplicity HTN-3, the first randomized, sham-controlled trial, failed to confirm the previously reported BP-lowering effects of RDN, although definitive conclusions cannot be drawn due to a number of study limitations. Consequently, although some centers halted their RDN programs, research continues and both the concept of denervation and treatment strategies are being redefined. A new generation of sham-controlled trials is currently underway with the aim of detecting which patients are expected to achieve the most beneficial effect from RDN. In this article, we examine the current data on RDN and discuss some insights and future opportunities.
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Affiliation(s)
- Enrico Boschetti
- Dipartimento di Medicina, Università degli Studi di Perugia, Perugia, Italy
- Struttura Complessa di Cardiologia, Azienda Ospedaliero-Universitaria di Terni, Terni, Italy
| | - Yahya Alrashdi
- Dipartimento di Medicina, Università degli Studi di Perugia, Perugia, Italy
| | - Giuseppe Schillaci
- Dipartimento di Medicina, Università degli Studi di Perugia, Perugia, Italy.
- Struttura Complessa di Medicina Interna, Azienda Ospedaliero-Universitaria di Terni, Piazzale Tristano di Joannuccio, 1, 05100, Terni, Italy.
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Burchell AE, Chan K, Ratcliffe LEK, Hart EC, Saxena M, Collier DJ, Jain AK, Mathur A, Knight CJ, Caulfield MJ, Paton JFR, Nightingale AK, Lobo MD, Baumbach A. Controversies Surrounding Renal Denervation: Lessons Learned From Real-World Experience in Two United Kingdom Centers. J Clin Hypertens (Greenwich) 2016; 18:585-92. [PMID: 26857092 DOI: 10.1111/jch.12789] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 12/18/2015] [Accepted: 12/20/2015] [Indexed: 11/27/2022]
Abstract
Renal denervation (RDN) is a therapy that targets treatment-resistant hypertension (TRH). The Renal Denervation in Patients With Uncontrolled Hypertension (Symplicity) HTN-1 and Symplicity HTN-2 trials reported response rates of >80%; however, sham-controlled Symplicity HTN-3 failed to reach its primary blood pressure (BP) outcome. The authors address the current controversies surrounding RDN, illustrated with real-world data from two centers in the United Kingdom. In this cohort, 52% of patients responded to RDN, with a 13±32 mm Hg reduction in office systolic BP (SBP) at 6 months (n=29, P=.03). Baseline office SBP and number of ablations correlated with office SBP reduction (R=-0.47, P=.01; R=-0.56, P=.002). RDN appears to be an effective treatment for some patients with TRH; however, individual responses are highly variable. Selecting patients for RDN is challenging, with only 10% (33 of 321) of the screened patients eligible for the study. Medication alterations and nonadherence confound outcomes. Adequate ablation is critical and should impact future catheter design/training. Markers of procedural success and improved patient selection parameters remain key research aims.
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Affiliation(s)
- Amy E Burchell
- CardioNomics Research Group, Clinical Research & Imaging Centre-Bristol, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, UK.,School of Clinical Sciences, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Kenneth Chan
- William Harvey Heart Centre, NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, London, UK.,Barts Blood Pressure Clinic, Barts Health NHS Trust, London, UK
| | - Laura E K Ratcliffe
- CardioNomics Research Group, Clinical Research & Imaging Centre-Bristol, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, UK.,School of Physiology, Pharmacology & Neuroscience, Biomedical Sciences, University of Bristol, Bristol, UK
| | - Emma C Hart
- CardioNomics Research Group, Clinical Research & Imaging Centre-Bristol, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, UK.,School of Physiology, Pharmacology & Neuroscience, Biomedical Sciences, University of Bristol, Bristol, UK
| | - Manish Saxena
- William Harvey Heart Centre, NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, London, UK.,Barts Blood Pressure Clinic, Barts Health NHS Trust, London, UK
| | - David J Collier
- William Harvey Heart Centre, NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, London, UK
| | - Ajay K Jain
- William Harvey Heart Centre, NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, London, UK.,Department of Cardiology, London Chest Hospital, Barts Health NHS Trust, London, UK
| | - Anthony Mathur
- William Harvey Heart Centre, NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, London, UK.,Department of Cardiology, London Chest Hospital, Barts Health NHS Trust, London, UK
| | - Charles J Knight
- William Harvey Heart Centre, NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, London, UK.,Department of Cardiology, London Chest Hospital, Barts Health NHS Trust, London, UK
| | - Mark J Caulfield
- William Harvey Heart Centre, NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, London, UK.,Barts Blood Pressure Clinic, Barts Health NHS Trust, London, UK
| | - Julian F R Paton
- CardioNomics Research Group, Clinical Research & Imaging Centre-Bristol, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, UK.,School of Physiology, Pharmacology & Neuroscience, Biomedical Sciences, University of Bristol, Bristol, UK
| | - Angus K Nightingale
- CardioNomics Research Group, Clinical Research & Imaging Centre-Bristol, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, UK
| | - Melvin D Lobo
- William Harvey Heart Centre, NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, London, UK.,Barts Blood Pressure Clinic, Barts Health NHS Trust, London, UK
| | - Andreas Baumbach
- CardioNomics Research Group, Clinical Research & Imaging Centre-Bristol, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, UK.,School of Clinical Sciences, University of Bristol, Bristol Royal Infirmary, Bristol, UK
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Piccoli GB, Attini R, Parisi S, Vigotti FN, Daidola G, Deagostini MC, Ferraresi M, De Pascale A, Porpiglia F, Veltri A, Todros T. Excessive urinary tract dilatation and proteinuria in pregnancy: a common and overlooked association? BMC Nephrol 2013; 14:52. [PMID: 23446427 PMCID: PMC3600000 DOI: 10.1186/1471-2369-14-52] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 02/07/2013] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Proteinuria and dilatation of the urinary tract are both relatively common in pregnancy, the latter with a spectrum of symptoms, from none to severe pain and infection. Proteinuria is a rare occurrence in acute obstructive nephropathy; it has been reported in pregnancy, where it may pose a challenging differential diagnosis with pre-eclampsia.The aim of the present study is to report on the incidence of proteinuria (≥ 0.3; ≥ 0.5 g/day) in association with symptomatic-severe urinary tract dilatation in pregnancy. METHODS Case series. SETTING Nephrological-Obstetric Unit dedicated to pregnancy and kidney diseases (January 2000-April 2011). SOURCE database prospectively updated since the start of the Unit. Retrospective review of clinical charts identified as relevant on the database, by a nephrologist and an obstetrician. RESULTS From January 2000 to April 2011, 262 pregnancies were referred. Urinary tract dilatation with or without infection was the main cause of referral in 26 cases (predominantly monolateral in 19 cases): 23 singletons, 1 lost to follow-up, 1 twin and 1 triplet. Patients were referred for urinary tract infection (15 cases) and/or renal pain (10 cases); 6 patients were treated by urologic interventions ("JJ" stenting). Among them, 11 singletons and 1 triple pregnancy developed proteinuria ≥ 0.3 g/day (46.1%). Proteinuria was ≥ 0.5 g/day in 6 singletons (23.1%). Proteinuria resolved after delivery in all cases. No patient developed hypertension; in none was an alternative cause of proteinuria evident. No significant demographic difference was observed in patients with renal dilatation who developed proteinuria versus those who did not. An association with the presence of "JJ" stenting was present (5/6 cases with proteinuria ≥ 0.5 g/day), which may reflect both severer obstruction and a role for vescico-ureteral reflux, induced by the stent. CONCLUSIONS Symptomatic urinary tract dilatation may be associated with proteinuria in pregnancy. This association should be kept in mind in the differential diagnosis with other causes of proteinuria in pregnancy, including pre-eclampsia.
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