Effects of Renal Denervation vs Sham in Resistant Hypertension After Medication Escalation: Prespecified Analysis at 6 Months of the RADIANCE-HTN TRIO Randomized Clinical Trial

Importance

Although early trials of endovascular renal denervation (RDN) for patients with resistant hypertension (RHTN) reported inconsistent results, ultrasound RDN (uRDN) was found to decrease blood pressure (BP) vs sham at 2 months in patients with RHTN taking stable background medications in the Study of the ReCor Medical Paradise System in Clinical Hypertension (RADIANCE-HTN TRIO) trial.

Objectives

To report the prespecified analysis of the persistence of the BP effects and safety of uRDN vs sham at 6 months in conjunction with escalating antihypertensive medications.

Design, Setting, and Participants

This randomized, sham-controlled, clinical trial with outcome assessors and patients blinded to treatment assignment, enrolled patients from March 11, 2016, to March 13, 2020. This was an international, multicenter study conducted in the US and Europe. Participants with daytime ambulatory BP of 135/85 mm Hg or higher after 4 weeks of single-pill triple-combination treatment (angiotensin-receptor blocker, calcium channel blocker, and thiazide diuretic) with estimated glomerular filtration rate (eGFR) of 40 mL/min/1.73 m2 or greater were randomly assigned to uRDN or sham with medications unchanged through 2 months. From 2 to 5 months, if monthly home BP was 135/85 mm Hg or higher, standardized stepped-care antihypertensive treatment starting with aldosterone antagonists was initiated under blinding to treatment assignment.

Interventions

uRDN vs sham procedure in conjunction with added medications to target BP control.

Main Outcomes and Measures

Six-month change in medications, change in daytime ambulatory systolic BP, change in home systolic BP adjusted for baseline BP and medications, and safety.

Results

A total of 65 of 69 participants in the uRDN group and 64 of 67 participants in the sham group (mean [SD] age, 52.4 [8.3] years; 104 male [80.6%]) with a mean (SD) eGFR of 81.5 (22.8) mL/min/1.73 m2 had 6-month daytime ambulatory BP measurements. Fewer medications were added in the uRDN group (mean [SD], 0.7 [1.0] medications) vs sham (mean [SD], 1.1 [1.1] medications; P = .045) and fewer patients in the uRDN group received aldosterone antagonists at 6 months (26 of 65 [40.0%] vs 39 of 64 [60.9%]; P = .02). Despite less intensive standardized stepped-care antihypertensive treatment, mean (SD) daytime ambulatory BP at 6 months was 138.3 (15.1) mm Hg with uRDN vs 139.0 (14.3) mm Hg with sham (additional decreases of -2.4 [16.6] vs -7.0 [16.7] mm Hg from month 2, respectively), whereas home SBP was lowered to a greater extent with uRDN by 4.3 mm Hg (95% CI, 0.5-8.1 mm Hg; P = .03) in a mixed model adjusting for baseline and number of medications. Adverse events were infrequent and similar between groups.

Conclusions and Relevance

In this study, in patients with RHTN initially randomly assigned to uRDN or a sham procedure and who had persistent elevation of BP at 2 months after the procedure, standardized stepped-care antihypertensive treatment escalation resulted in similar BP reduction in both groups at 6 months, with fewer additional medications required in the uRDN group.

Trial Registration

ClinicalTrials.gov Identifier: NCT02649426.

Surgical and Ablative Treatment for Metastatic Adenocarcinoma to the Liver from Unknown Primary Tumor

Metastatic adenocarcinoma to the liver from an unknown primary tumor (UPT) carries a poor prognosis, with a median survival of 5 months. Chemotherapy has not significantly improved outcome, and effective treatment is yet to be established in these patients. We examined our experience with surgical resection and ablation of this disease to determine clinico-pathologic characteristics and treatment outcomes. We undertook a retrospective chart review of 157 patients who were treated for metastatic disease to the liver with resection or radiofrequency ablation (RFA) between 1999 and 2003. Seven patients were identified with unknown primary malignancy. Evaluation of the seven patients included complete history and physical examination, complete blood count, routine chemistries, stool Hemoccult test, chest radiograph, and computed tomography (CT) of the abdomen and pelvis. In addition, the three female patients had breast examinations and mammography. Adenocarcinoma histology was determined via CT-guided liver biopsy in all patients. Other diagnostic tests, including whole-body positron emission tomography to the measurement of various serum tumor markers, were performed in the majority of the patients. There were nine total lesions treated; six with RFA and three with hepatic resection. Median diameter of the lesions was 5.4 cm (range, 1.3–15). Two patients were treated with adjuvant and three patients with neoadjuvant and adjuvant chemotherapy. Extrahepatic sites of metastases, adrenal and skeletal, were discovered in 1 patient prior to treatment. With a median follow-up of 9 months, 1 patient is currently alive with no evidence of disease, 4 patients are alive with disease, and 2 patients died of disease. Median disease-free-interval following treatment was 6.5 months. To date, optimal treatment for metastatic adenocarcinoma to the liver UPT remains unclear. Localized treatment involving RFA or hepatic resection may be a promising addition to chemotherapy in the management of this disease.

Surgical and ablative treatment for metastatic adenocarcinoma to the liver from unknown primary tumor

Metastatic adenocarcinoma to the liver from an unknown primary tumor (UPT) carries a poor prognosis, with a median survival of 5 months. Chemotherapy has not significantly improved outcome, and effective treatment is yet to be established in these patients. We examined our experience with surgical resection and ablation of this disease to determine clinico-pathologic characteristics and treatment outcomes. We undertook a retrospective chart review of 157 patients who were treated for metastatic disease to the liver with resection or radiofrequency ablation (RFA) between 1999 and 2003. Seven patients were identified with unknown primary malignancy. Evaluation of the seven patients included complete history and physical examination, complete blood count, routine chemistries, stool Hemoccult test, chest radiograph, and computed tomography (CT) of the abdomen and pelvis. In addition, the three female patients had breast examinations and mammography. Adenocarcinoma histology was determined via CT-guided liver biopsy in all patients. Other diagnostic tests, including whole-body positron emission tomography to the measurement of various serum tumor markers, were performed in the majority of the patients. There were nine total lesions treated; six with RFA and three with hepatic resection. Median diameter of the lesions was 5.4 cm (range, 1.3-15). Two patients were treated with adjuvant and three patients with neoadjuvant and adjuvant chemotherapy. Extrahepatic sites of metastases, adrenal and skeletal, were discovered in 1 patient prior to treatment. With a median follow-up of 9 months, 1 patient is currently alive with no evidence of disease, 4 patients are alive with disease, and 2 patients died of disease. Median disease-free-interval following treatment was 6.5 months. To date, optimal treatment for metastatic adenocarcinoma to the liver UPT remains unclear. Localized treatment involving RFA or hepatic resection may be a promising addition to chemotherapy in the management of this disease.

Is there a learning curve in diagnosing urolithiasis with noncontrast helical computed tomography?

OBJECTIVE

To report one department's experience with helical computed tomographic (HCT) evaluation of patients with suspected renal colic to diagnose ureteral calculi; to determine whether there is a learning curve in performing HCT in this context; and to determine whether HCT for the evaluation of renal colic exposes patients to more radiation than the standard intravenous pyelography (IVP) combined with nephrotomography.

METHODS

All patients presenting to the emergency department with flank or abdominal pain were evaluated with nonreformatted noncontrast HCT. To determine changes in diagnostic accuracy, patients were divided into 2 groups: those evaluated between September 1996 and January 1997 (group 1, 67 patients), and those seen from February to June 1997 (group 2, 53 patients). A radiation exposure study was performed using phantoms, and radiation exposure for HCT, IVP and nephrotomography was measured.

RESULTS

Review of HCT scans to diagnose ureteral calculi had a sensitivity of 91.7%, specificity of 82.6%, and accuracy of 87.2% in group 1, and a sensitivity of 95.5%, specificity of 86.7%, and accuracy of 91.9% in group 2. Patients undergoing IVP with nephrotomography were exposed to an effective dose equivalent of 343 mrem (dSv) (for men) and 664 mrem (for women). The effective dose equivalent for an HCT scan was 180 mrem.

CONCLUSION

HCT offers excellent, rapid diagnostic accuracy without the need for intravenous contrast medium and with a lower radiation exposure level than IVP in evaluating patients with acute flank pain. There is a small but real learning curve in evaluating patients with acute flank pain with HCT.