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Abstract：
This narrative review aims to assess the pathophysiology, diagnosis, and treatment of resistant hypertension (RH) in end-stage kidney disease (ESKD) patients on dialysis, with a specific focus on the effect of renal denervation (RDN) on short-term and long-term blood pressure (BP) control. Additionally, we share our experience with the use of RDN in an amyloidotic patient undergoing hemodialysis with RH.
High BP, an important modifiable cardiovascular risk factor, is often observed in patients in ESKD, despite the administration of multiple antihypertensive medications. However, in clinical practice, it remains challenging to identify RH patients on dialysis treatment because of the absence of specific definition for RH in this context. Moreover, the use of invasive approaches, such as RDN, to treat RH is limited by the exclusion of patients with reduced renal function (eGFR < 45 mL/min/1.73 m3) in the clinical trials. Nevertheless, recent studies have reported encouraging results regarding the effectiveness of RDN in stage 3 and 4 chronic kidney disease (CKD) and ESKD patients on dialysis, with reductions in BP of nearly up to 10 mmhg. Although multiple underlying pathophysiological mechanisms contribute to RH, the overactivation of the sympathetic nervous system in ESKD patients on dialysis plays a crucial role. The diagnosis of RH requires both confirmation of adherence to antihypertensive therapy and the presence of uncontrolled BP values by ambulatory BP monitoring or home BP monitoring. Treatment involves a combination of nonpharmacological approaches (such as dry weight reduction, sodium restriction, dialysate sodium concentration reduction, and exercise) and pharmacological treatments. A promising approach for managing of RH is based on catheter-based RDN, through radiofrequency, ultrasound, or alcohol infusion, directly targeting on sympathetic overactivity.
High BP, an important modifiable cardiovascular risk factor, is often observed in patients in ESKD, despite the administration of multiple antihypertensive medications. However, in clinical practice, it remains challenging to identify RH patients on dialysis treatment because of the absence of specific definition for RH in this context. Moreover, the use of invasive approaches, such as RDN, to treat RH is limited by the exclusion of patients with reduced renal function (eGFR < 45 mL/min/1.73 m3) in the clinical trials. Nevertheless, recent studies have reported encouraging results regarding the effectiveness of RDN in stage 3 and 4 chronic kidney disease (CKD) and ESKD patients on dialysis, with reductions in BP of nearly up to 10 mmhg. Although multiple underlying pathophysiological mechanisms contribute to RH, the overactivation of the sympathetic nervous system in ESKD patients on dialysis plays a crucial role. The diagnosis of RH requires both confirmation of adherence to antihypertensive therapy and the presence of uncontrolled BP values by ambulatory BP monitoring or home BP monitoring. Treatment involves a combination of nonpharmacological approaches (such as dry weight reduction, sodium restriction, dialysate sodium concentration reduction, and exercise) and pharmacological treatments. A promising approach for managing of RH is based on catheter-based RDN, through radiofrequency, ultrasound, or alcohol infusion, directly targeting on sympathetic overactivity.
摘要：
目的：这篇叙述性综述旨在评估病理生理学，诊断,和难治性高血压（RH）的终末期肾病（ESKD）患者的透析治疗，特别关注肾脏去神经（RDN）对短期和长期血压（BP）控制的影响。此外,我们分享我们在接受RH血液透析的淀粉样变性患者中使用RDN的经验.
结果：高BP，一个重要的可改变的心血管危险因素，经常在ESKD患者中观察到，尽管服用了多种抗高血压药物。然而,在临床实践中，由于在这种情况下缺乏对RH的具体定义,因此鉴定接受透析治疗的RH患者仍然具有挑战性.此外，使用侵入性方法，如RDN，在临床试验中排除肾功能降低(eGFR<45mL/min/1.73m3)的患者,限制了RH的治疗.然而，最近的研究报告了关于RDN在3期和4期慢性肾脏病（CKD）和ESKD透析患者中的有效性的令人鼓舞的结果，血压降低近10mmhg。尽管多种潜在的病理生理机制有助于RH，在ESKD透析患者的交感神经系统过度激活中起着至关重要的作用。RH的诊断需要通过动态BP监测或家庭BP监测来确认对抗高血压治疗的依从性以及不受控制的BP值的存在。治疗涉及非药物方法的组合(如干重减少，限钠,透析液钠浓度降低，和运动）和药物治疗。一种有前途的RH管理方法是基于基于导管的RDN，通过射频，超声，或酒精输液，直接针对交感神经过度活动。
结果：高BP，一个重要的可改变的心血管危险因素，经常在ESKD患者中观察到，尽管服用了多种抗高血压药物。然而,在临床实践中，由于在这种情况下缺乏对RH的具体定义,因此鉴定接受透析治疗的RH患者仍然具有挑战性.此外，使用侵入性方法，如RDN，在临床试验中排除肾功能降低(eGFR<45mL/min/1.73m3)的患者,限制了RH的治疗.然而，最近的研究报告了关于RDN在3期和4期慢性肾脏病（CKD）和ESKD透析患者中的有效性的令人鼓舞的结果，血压降低近10mmhg。尽管多种潜在的病理生理机制有助于RH，在ESKD透析患者的交感神经系统过度激活中起着至关重要的作用。RH的诊断需要通过动态BP监测或家庭BP监测来确认对抗高血压治疗的依从性以及不受控制的BP值的存在。治疗涉及非药物方法的组合(如干重减少，限钠,透析液钠浓度降低，和运动）和药物治疗。一种有前途的RH管理方法是基于基于导管的RDN，通过射频，超声，或酒精输液，直接针对交感神经过度活动。
