1. Temi caldi in Nefrologia La denervazione dell’arteria renale nel trattamento dell’ipertensione arteriosa Luigi Amoroso UOC Nefrologia e Dialisi Ospedale “SS Annunziata” Chieti

2. I numeri dell’Ipertensione Arteriosa a livello mondiale 7,6 milioni di morti premature/anno (13,6% del totale) 92 milioni di anni di disabilità (6,0% del totale) 54% degli ictus, 47% delle cardiopatie ischemiche 70 miliardi di dollari all’anno per l’insufficiente controllo della pressione ( 10% della spesa mondiale annua per la salute) 3600 miliardi di costi indiretti/anno Lewington S.et al.; Lancet 2002 Lawes CM.; Lancet 2008 OMS : 20111 Stroke 35-40% Miocardial Infarction20-25% Heart Failure50% Total CV Mortality25% Benefits of Lowering BP He W. et al.; Am Heart J 1999 Kannel WB. et al.; JAMA 1996 Moser M. et al.; J Am Coll Cadiol 1996

5. Pathophysiological Mechanism of Hypertention Oparil S. et al.; Ann Intern Med 2003

6. Grassi G. et al.; Exp Physiol 2009 ** MSNA (burst per 100 heart beats) MAP (mmHg) Progressive increase in muscle sympathetic nerve activity in normotensive control subjects (light green square), mild- to-moderate (red square) and more severe essential hypertensive patients (dark green square) ** P < 0.01 between groups. Muscle Sympathetic Nerve Activity

7. Renal Sympathetic Denervation Baroreflex Activation Therapy (Rheos carotid sinus stimulator) Device-based approaches to the treatment of Resistant Hypertension

8. ↑ Contractility ↑ Heart rate Hypertrophy Arrhythmia Heart Failure Renal Sympathetic Nerve Activity: Kidney as Origin & Recipient of Central Sympathetic Drive Afferent Nerves Vasoconstriction Atherosclerosis Insulin resistance ↑ Renin Release  RAAS activation ↑ Sodium Retention ↓ Renal Blood Flow Efferent Nerves Blood Pressure

9. Vessel Lumen Media Adventitia Renal Nerves

10. Renal Nerve Ablation Devices Radiofrequency Ablation - Medtronic Semplicity - St. Jude EnligHTN - Convidien One Shot system - Vessix Vascular V2 system Ultrasound - ReCor Medical Paradise - Kona Medical Chemical Ablation ( Guanethedine,Ethanol, Botox B, Vincristine ) - Mercator MedSystems

11. 11 Symplicity Catheter System (Medtronic) Steerable tip

12. Technique of treatment From distal to proximal 4-6 ablation spots 2 min for each spot ≥ 5 mm of distance

13. What are the effects on BP?

14. ESC Expert Consensus:European Heart Journal 2013 Average BP reduction : -29/-11 mmHg

15. Reduction PAS ≥ 10 mmHg: (Mean baseline BP: 178/97±18/16 mmHg) Responders: 84% Non-responders: 16% Reduction PAS ≥ 10 mmHg: (Mean baseline BP: 176/98±17/14 mmHg) Responders: 92% Non-responders: 8% Symplicity HTN-1 Investigators: Hypertension 2011

16. Symplicity HTN-1: Reduction through 3 years Krum H. : American College of Cardiology Annual Meeting 2012 BP change (mmHg) 1 Mo 3 Mo 6 Mo 12 Mo 18 Mo 24 Mo 30 Mo 36 Mo (n=143) (n=148) (n=144) (n=130) (n=107) (n=59) (n=24) (n=24) -19 -21 -22 -26 -33 -9 -26 -33 -10 -13 -12 -15 -14 -19 Systolic BP Diastolic BP P<0.01 for Δ from BL for all time points

17. The Symplicity HTN-2 Trial: MEDICATION CHANGES RDNControlP-value (n=49) (n=51) Med Dose Decrease (%)10 (20%) 3 (6%) 0.04 Med Dose Increase (%) 4 (8%) 6 (12%) 0.74 Symplicity HTN-2 Investigators: Lancet 2010

18. Does RDN reduce Sympathetic tone?

19. Schlaich MP et al.; NEJM 2009 Baseline 30 Days after Bilateral Denervation Baseline 30 Days after Bilateral Denervation A Kidney SpilloverB Whole-Body Spillover Norepinephrine Spillover (ng/min) Norepinephrine Spillover (ng/min) Mean Systolic/Diastolic Office BP 161/107 mmHg (baseline) 141/90 mmHg (30 days after RDN) Direct Measurement of Reduced Sympathetic Nerve Activity - 48% - 75% - 42%

20. What are the risks?

21. Semplicity HTN-1 Trial Short-term safety outcomes Renal artery dissection before energy delivery (n 1) Femoral artery pseudoaneurysm at access site (n 3) Long-term safety outcomes No renal vascular complication Semplicity HTN-2 Trial Short-term safety outcomes Intraprocedural bradicardia (n 7) Post procedural drop in BP (n 1) Femoral artery pseudoaneurysm at access site (n 1) Long-term safety outcomes No renal vascular complication

22. After 5 months, due to recurrent hypertension, renal angiography was performed demonstrating an 80% ostial and 70% mid-segment right main renal artery stenosis and a mid 50% stenosis in the right upper pole accessory renal artery Kaltenbach B. et al.: JACC 2012 After six months increse of BP. Renal Angiography showed a 75% stenosis near the ostium of the right renal artery Lancet 2012

23. -Local loss of the endotelial monolayer as acute phase -Acute edematous cellular swelling and connective tissue coagulation within the medial and adventitial layer -Subacute reduction in nerve fascicle quantity and size -Tickening of perinerium and reduced neurofilament of nerve J Hypertens 2012 Clin Res Cardiol 2011 Fibrosis of 10%-25% of total media and underlying adventitia with mild disruption of the external elastic lamina Nerve fibrosis, replacement of nerve fascicles with fibrous cennective tissue and thickening of the perineurium 6 months

27. The Symplicity HTN-2 Trial: Renal Function Changes Renal denervation groupControl group Difference in mean change (95%Cl) eGFR (mL/min per 1,73 m 2 ) Serum creatinine (μmol/L) Cystatin C (mg/L) eGFR= Calculated on the basis of MDRD Patients (n°)Mean change (SD)Patients (n°)Mean change (SD) p value 49 0.2 (11) 51 0.9 (12) -0.7 (-5.4 to 3.9) 0.76 49 0.2 (17.6) 51 -1.1 (10.3) 1.3 (-4.5 to 7.0) 0,67 37 0.1 (0.2) 40 0.0 (0.1) 0.0 (0.0 to 0.1) 0.31 Symplicity HTN-2 Investigators: Lancet 2010

28. The Symplicity HTN-1 Trial: RENAL FUNCTION eGFR (mL/min per 1,73 m 2 ) months 1 3 6 12 24 n° pts + 0.1 - 1.6 - 0.1 - 2.9 - 16.0 112 102 87 64 10 Symplicity HTN-1 Investigators: Hypertension 2011

29. What are the eligibility criteria?

30. Office-based SBP ≥160 mmHg (≥150 mmhg diabetes type 2) ≥ 3 antihypertensive drugs in adequate dosage and combination (incl. diuretic) Lifestyle modification Exclusion of secondary hypertension Exclusion of pseudo-resistance using ABPM Eligible renal arteries: no polar or accessory arteries, no renal artery stenosis, main renal arteries of < 4 mm in diameter or < 20 mm in lenght, no prior revas- scularization (stenting/PTA) Preserved renal function (eGFR ≥ 45 ml/min/1.73m2) Pts should be referred to Hypertension Excellence Centers

32. Future applications of RDN

33. Controls HT Obese CHF MS RF bs/min MSNA * ** * * * * * * * Behaviour of muscle (MSNA) and skin sympathetic nerve activity (SSNA) in healthy sunjects and in patients with hypertension (HT), obesity (OB), congestive hearth failure (CHF), methabolic syndrome (MS) or renal failure (RF) Grassi G. et al.; Exp Physiol 2009

34. Mahfoud F. et al.; Circulation 2011

35. Mahfoud F. et al.: Circulation 2011 Change in fasting glucise (mg/dl) Change in fasting C-peptide (ng/dl) A B C D -8,9 +3,9 -9,4 +0,9 Change in fasting insulin (μIU/dl) Change in HOMA-IR (ng/dl) P=0.001 1 month3 month P=0.402 P=0.043P=0.039 P=0.847 p for interaction (ANOVA)=0,043p for interaction (ANOVA)=0,016 +0,5+6,4 -8,7-11,6 P=0.129 P=0.984 P=0.036 P=0.006 1 month3 month p for interaction (ANOVA)=0,031 +0,2 P=0.699 P=0.776 P=0.006 P=0.002 -2,0-2,3 1 month3 month 1 month3 month +0,3 -3,0-3,5 +2,1 P=0.085 P=0.734 P=0.008 p for interaction (ANOVA)=0,003

36. NDT 2012 JACC 2012 Curr Cardiol Rep 2012

37. J Am Soc Nephrol 2012

38. Limitations RDN does not cause universal BP lowering Only a small number of patients have been exposed to RDN and the follow-up is short Lacking of randomized blinded studies Lacking of any procedural marker that might identify good responders to RDN Lacking of standardized certification of RDN centers