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Renale Denervierung

Atueller Stand und Perspektiven

Renal denervation

Current state and future perspectives

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Zusammenfassung

Die optimale Therapie der arteriellen Hypertonie bleibt trotz einer Vielzahl zur Verfügung stehender Medikamente eine große Herausforderung, und der Zielwert wird bei vielen Patienten nicht erreicht, obwohl der Zusammenhang zwischen Bluthochdruck und kardiovaskulären Ereignissen heutzutage unumstritten ist. Die Gründe für das mangelnde Erreichen des Zielblutdrucks sind vielfältig und beinhalten Compliance-Probleme und Medikamentennebenwirkungen, aber auch die Therapierefraktärität. Bei der therapierefraktären arteriellen Hypertonie hat das Ungleichgewicht des vegetativen Nervensystems zugunsten des Sympathikus eine übergeordnete Bedeutung. Die Notwendigkeit, Menschen mit einer therapierefraktären arteriellen Hypertonie adäquat behandeln zu können, und das Wissen, durch eine Reduzierung der Sympathikusaktivität auch eine Reduzierung des Blutdrucks zu erreichen, haben zur Entwicklung der katheterbasierten renalen Sympathikusdenervation (kurz: „renale Denervierung“) geführt. Dabei werden katheterbasiert sympathische Nervenfasern entlang der Nierenarterien abladiert. Die Resultate der bekanntesten Studien – Symplicity HTN-1 und HTN-2 – haben das Interesse der katheterbasierten renalen Denervierung zur Behandlung der therapierefraktären arteriellen Hypertonie bei Ärzten und auch bei Patienten weltweit geweckt. Durch Reduzierung der Sympathikusaktivität konnten neben der Blutdruckreduktion auch zusätzlich potenzielle positive Effekte auf den Glukosestoffwechsel, das Schlafapnoe-Syndrom sowie die Herz- und Niereninsuffizienz gezeigt werden. Diese Erkenntnisse haben dazu geführt, dass in kürzester Zeit eine Vielzahl neuer Systeme zur renalen Denervierung entwickelt wurden. Inwieweit die katheterbasierte renale Ablationstherapie dauerhaft zur Therapie der therapierefraktären Hypertonie eingesetzt werden kann, welche weiteren Indikationen sich hierfür ergeben und welche Ergebnisse mit den neueren Kathetersystemen erzielt werden, muss durch größere Studien und Langzeitergebnisse bestätigt bzw. geprüft werden.

Abstract

Hypertension is a well-known risk factor for major cardiovascular events. Despite advances in medical therapy, sufficient treatment of hypertension remains unsatisfying in a substantial number of patients and is therefore one of the main challenges in modern medicine. In Germany 5–15 % of patients with hypertension suffer from resistant hypertension with elevated blood pressure despite the use of at least three antihypertensive drugs. Additionally patients often suffer from side effects. In patients with resistant hypertension the important role of the sympathetic nervous system with increased sympathetic activity is well known. In the past surgical sympathectomy with extended removal of sympathetic ganglia was performed to reduce blood pressure in patients with malignant hypertension. The positive effect of this highly invasive procedure on blood pressure led to the development of new strategies for the treatment of uncontrolled hypertension. One of the novel procedures includes catheter-based renal sympathetic denervation. The most common system is the radiofrequency ablation catheter (Symplicity®, Medtronic, Minneapolis, USA) which ablates the nerve fibers in the adventitia of the renal arteries by using high-frequency energy. As the results of the Symplicity trials (HTN-1 and HTN-2) showed significant reduction of systolic and diastolic blood pressure after renal denervation there is growing interest in this novel procedure. Moreover, by reducing the sympathetic activity after renal denervation early results indicate a positive impact on glucose metabolism, sleep apnea syndrome, as well as heart and renal failure. These effects led to the development of many different devices for renal denervation; however, trials with a higher number of patients and longer follow-up need to confirm these initially promising results and the value of newer devices. Until then renal denervation should not be regarded as standard therapy for arterial hypertension or an alternative to medical antihypertensive treatment and should be reserved for selected patients with resistant hypertension and specialized medical centres.

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Interessenkonflikt

H. Bruck u. T. Konorza waren Site Principal Investigators der Simplicity-HTN2-Studie, die von der Firma Adrian Inc., USA, gesponsert wurde. P. Kahlert ist Clinical Proctor für Edwards Lifesciences Inc. Der korrespondierende Autor gibt für sich und die weiteren Koautoren an, dass kein Interessenkonflikt besteht.

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Authors and Affiliations

  1. Klinik für Kardiologie, Westdeutsches Herzzentrum, Universitätsklinikum Essen, Universität Essen-Duisburg, Hufelandstr. 55, 45147, Essen, Deutschland

    K. Kara, P. Kahlert, B. Plicht, A.A. Mahabadi, T. Konorza & R. Erbel

  2. Klinik für Nephrologie, Universitätsklinikum Essen, Universität Essen-Duisburg, Essen, Deutschland

    H. Bruck

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  1. K. Kara
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  2. H. Bruck
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  3. P. Kahlert
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  4. B. Plicht
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  5. A.A. Mahabadi
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  6. T. Konorza
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  7. R. Erbel
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Correspondence to K. Kara.

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Kara, K., Bruck, H., Kahlert, P. et al. Renale Denervierung. Herz 37, 746–753 (2012). https://doi.org/10.1007/s00059-012-3689-7

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