Targeting the sympathetic nervous system: critical issues in patient selection, efficacy, and safety of renal denervation.
Targeting the sympathetic nervous system: critical issues in patient selection, efficacy, and safety of renal denervation.
复制标题
DOI：
10.1161/hypertensionaha.113.02144
复制
发表时间：
2014-03
期刊：
影响因子：
8.3
通讯作者：
M. Schlaich;M. Esler;G. Fink;J. Osborn;D. Euler
中科院分区：
文献类型：
--
作者：
M. Schlaich;M. Esler;G. Fink;J. Osborn;D. Euler
在过去几十年中已经积累了证据，强烈表明交感神经系统的异常有助于多种疾病状态的发展和维持，包括高血压、心力衰竭、糖尿病、睡眠呼吸暂停、肾病、1肾神经已被确定为实验动物和人类高血压发展的重要贡献者。2患者原发性高血压和其他疾病状态的患者通常具有增加的对肾脏的传出交感神经驱动，如肾去甲肾上腺素溢出率升高所证明的。1，2除了增加的肾传出神经活动之外，在原发性高血压患者中存在增加的肾传入神经活动的间接证据。3非选择性交感神经切除术已被有效地用作严重高血压的治疗，4例患者在5年随访时的结局有显著差异。最近开发的血管内导管技术已经允许使用经由肾动脉腔递送的射频（RF）能量来选择性地对人类肾脏进行去神经支配。5尽管使用这种微创技术的初始临床试验已经证明了这种方法的安全性和有效性，但是已经提出了与长期安全性、作用机制、适当的患者选择、动态血压（BP）的降低、应答率的定义和水平、需要识别预测无应答的特征、延迟应答现象以及其他几个问题。基于导管的肾神经消融中断传出神经和传入神经（图1）。众所周知，肾交感神经传出神经的激活可以减少肾血流量，增加肾小管钠和水的重吸收，并增加肾素释放。2然而，有新的证据表明，在升高血压方面，肾传入信号可能与肾传出活动一样重要。肾传入神经的激活会导致...
Evidence has accumulated during the past several decades, strongly suggesting that abnormalities of the sympathetic nervous system contribute to the development and maintenance of multiple disease states, including hypertension, heart failure, diabetes mellitus, sleep apnea, kidney disease, and atrial fibrillation.1 The renal nerves have been identified as important contributors to the development of hypertension in both experimental animals and humans.2 Patients with essential hypertension and other disease states often have increased efferent sympathetic drive to the kidneys as demonstrated by elevated rates of renal norepinephrine spillover.1,2 In addition to increased renal efferent nerve activity, there is indirect evidence for increased renal afferent activity in patients with essential hypertension.3 Nonselective surgical sympathectomy has been effectively used as a treatment for severe hypertension,4 with a remarkable difference in outcomes at 5 years of follow-up. Recently developed endovascular catheter technology has allowed selective denervation of the human kidney using radiofrequency (RF) energy delivered via the renal artery lumen.5 Although the initial clinical trials with this minimally invasive technique have documented the safety and efficacy of such an approach, critical questions have been raised pertaining to long-term safety, mechanisms of action, appropriate patient selection, reductions in ambulatory blood pressure (BP), definition and level of responder rates, need for identification of characteristics that predict nonresponse, phenomenon of a delayed response, and several others.6 Here, we address several of these key questions. Catheter-based renal nerve ablation interrupts both efferent and afferent nerves (Figure 1). It is well established that activation of renal sympathetic efferents can decrease renal blood flow, increase tubular sodium and water reabsorption, and increase renin release.2 However, there is emerging evidence that renal afferent signaling may be as important as renal efferent activity in elevating BP. Activation of renal afferents can cause a …