The role of renal denervation for the treatment of hypertension in patients with chronic kidney disease: a position paper of the Italian Society of Nephrology

Hypertension is a clinical condition associated with an increase in cardiovascular morbidity and mortality. In chronic kidney disease (CKD), hypertension is also a driver of faster disease progression. Correct and appropriate treatment with antihypertensive medication reduces the risk of cardiovascular events and slows kidney disease progression. However, not all hypertensive patients achieve the desired blood pressure goals despite multiple antihypertensive therapies, and these are defined as patients with uncontrolled or resistant hypertension. Renal denervation has been successfully proposed to mitigate the hyperactivity of the sympathetic nervous system in patients with uncontrolled/resistant hypertension. The guidelines of the European Society of Cardiology and the European Society of Hypertension include renal denervation as a therapeutic option for treating hypertension in patients with uncontrolled or resistant hypertension. However, in patients with CKD, diffusion of the procedure has been limited by concerns over possible adverse effects on kidney function. Over the last few years, the improvement of the device-based procedure and the growing experience accumulated in several Nephrology centers have increased the use of renal denervation in patients with CKD. In patients with uncontrolled/resistant hypertension with a significant reduction of glomerular filtration rate (< 40 ml/min/1.73 m2), on dialysis, or living with a kidney transplant, the procedure significantly reduces blood pressure values over time without negative effects on kidney function. Taking into account the effectiveness of renal denervation in patients with uncontrolled or resistant hypertension and CKD, and the lack of defined indications concerning renal denervation in CKD, the Italian Society of Nephrology has decided to publish a position paper reviewing the available evidence in the medical literature.