Blood pressure and renal outcomes after renal denervation in patients with chronic kidney disease

Figures

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  Figure 1.. PRISMA flow diagram. n = number of records, PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

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  Figure 2.. RoB assessment of studies evaluating RDN in CKD. The traffic-light plot (upper panel) shows the judgment for each RoB domain across the 12 included studies (green = low risk, orange = some concerns, red = high risk). Domains assessed were: randomization process, deviations from intended interventions, missing outcome data, measurement of outcomes, and selection of reported results. The summary plot (lower panel) presents the overall distribution of risk judgments across all domains and studies. CKD = chronic kidney disease, RDN = renal denervation, RoB = risk of bias.

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  Figure 3.. Forest plots summarizing the effects of RDN in patients with CKD. (A) Change in office SBP; (B) change in office DBP; (C) change in 24-hour ambulatory SBP; (D) change in 24-hour ambulatory DBP; (E) change in renal function, expressed as eGFR (mL/min/1.73m2); (F) safety outcomes, expressed as pooled risk ratios for adverse events. Each black circle represents the effect estimate from an individual study with its 95% CI. The vertical dashed line indicates the line of no effect. The blue diamond at the bottom of each panel represents the pooled overall estimate with its 95% CI obtained from random-effects meta-analysis. ABPM = ambulatory blood pressure monitoring, CI = confidence interval, CKD = chronic kidney disease, DBP = diastolic blood pressure, eGFR = estimated glomerular filtration rate, RDN = renal denervation, SBP = systolic blood pressure.

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  Figure 4.. Funnel plot of studies evaluating RDN in patients with CKD. Each dot represents an individual study plotted according to its effect size (x-axis) and standard error (y-axis). The blue dashed vertical line indicates the pooled mean effect from random-effects meta-analysis, and the gray dashed lines represent the expected 95% confidence limits forming the funnel. Visual inspection of the funnel allows assessment of publication bias and small-study effects. Symmetry of points around the pooled effect suggests low bias, whereas asymmetry indicates possible heterogeneity or selective reporting. Statistical heterogeneity was quantified using the I2 statistic, with values above 50% considered substantial. Funnel plot asymmetry was evaluated with Egger regression test; a P value < .05 was considered significant for small-study effects. I2 = 58% → indicating moderate-to-high heterogeneity. Egger test P = .33 → not statistically significant, suggesting no strong evidence of small-study effects or publication bias. CKD = chronic kidney disease, RDN = renal denervation,

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  Figure 5.. Subgroup analysis of RDN outcomes according to CKD stage. Legend: Forest plots comparing the efficacy and safety of RDN between patients with CKD stages 2 to 4 and those with ESRD (CKD stage 5/ESRD). Subgroup analyses were performed for (A) office SBP, (B) office DBP, (C) 24-hour ambulatory SBP, (D) 24-hour ambulatory DBP, (E) renal function assessed by eGFR, and (F) safety outcomes. Black squares represent individual study effect estimates with 95% CI, while blue diamonds indicate pooled estimates derived using a random-effects model. Negative mean differences for blood pressure outcomes favor RDN, whereas renal function and safety outcomes are interpreted according to the direction of the pooled effect. This subgroup analysis demonstrates the consistency of blood pressure reduction and renal safety across different stages of CKD while highlighting potential differences between non-dialysis CKD and ESRD populations. ABPM = ambulatory blood pressure monitoring, CI = confidence interval, CKD = chronic kidney disease, DBP = diastolic blood pressure, eGFR = estimated glomerular filtration rate, ESRD = end-stage renal disease, RDN = renal denervation, SBP = systolic blood pressure.