Chronic kidney disease: role of sympathetic nervous system activation and potential benefits of renal denervation

The prevalence of chronic kidney disease (CKD) and end-stage renal disease continues to increase worldwide. Hypertension and diabetes are recognised as two major factors contributing to further progression of CKD. Importantly, progressive renal impairment increases cardiovascular morbidity and mortality. Despite advances in pharmacological antihypertensive and anti-diabetic approaches, the alarming number of patients developing nephropathy indicates the failure of the available treatment strategies. The relevance of sympathetic activation for the development and progression of chronic kidney disease is well established. Likewise, progressive renal failure results in exaggerated sympathetic activation leading to a vicious cycle, providing the rationale for the use of renal denervation to modulate directly the mechanisms underlying disease progression. While initial data on the safety and effectiveness of the procedure to lower BP were obtained in patients with resistant hypertension and preserved renal function, there are now preliminary data to suggest that this approach can also be applied safely in patients with stage 3-4 CKD. Similarly, first reports applying renal denervation in patients with end-stage renal disease on dialysis demonstrate favourable effects. If appropriately designed clinical trials can confirm these initial observations, renal denervation may become a valuable new treatment option for the large cohort of patients with CKD.