基于心脏电生理射频消融系统的去肾神经术应用于终末期肾病合并难治性高血压患者的有效性与安全性

Feasibility and safety of renal denervation in patients with end-stage renal disease complicated with resistant hypertension

摘要

目的 探讨去肾神经术（RDN）应用于终末期肾病（ESRD）合并难治性高血压（RHT）患者的可行性与安全性。方法 回顾性分析 2017 年 12 月至 2024 年 12 月福建医科大学附属第一医院接受 RDN 的 ESRD 患者的基线及随访资料。根据导致 ESRD 的病因分为三组，分别是糖尿病肾病组（DN 组）、慢性肾小球肾炎组（CG 组）和高血压肾硬化症组（HE 组）。使用美国雅培公司接触式光感应压力消融导管进行 RDN。通过 ENSITE 系统建立三维模型，消融导管由远及近在血管内四象限螺旋状对双侧肾动脉主干及分支逐点消融。每个位点消融 40 s，温度 40 ℃。肾动脉分支消融功率 8 W，主支消融功率 12 W。结果 共纳入 25 例 ESRD 患者，其中 DN 组 10 例，CG 组 8 例，HE 组 7 例。所有患者规律接受血液透析治疗并控制干体重。主支消融点数（15.04±2.62）个，分支消融点数（4.68±1.03）个，透视时间（23.64±6.89）min，造影剂用量（28.40±8.50）mL。各亚组消融前后阻抗、造影剂用量、透视时间上差异无统计学意义。HE 组主支和分支消融点数均最少。CG 组出现了 1 例血管夹层，植入了肾动脉支架，HE 组出现了 1 例假性动脉瘤。中位随访时间（7.90±1.55）个月。随访期间，DN 组和 CG 组各有 1 例失访。CG 组和 HE 组各有 1 例因心肌梗死死亡。CG 组和 HE 组各有 1 例主要不良心血管事件（MACE），均因心力衰竭住院。共对 21 例患者进行了术后随访。有 15 例（71.43%）患者对 RDN 有应答，分别是 DN 组 8 例（88.89%），CG 组 4 例（66.67%），HE 组 3 例（50.00%）。与术前相比，RDN 后患者诊室收缩压和舒张压、24 h 动态收缩压和舒张压均下降[诊室收缩压：（141.95±10.21）比（159.88±19.48）mmHg，t = 5.44，P＜0.001；诊室舒张压：（79.23±8.69）比（85.28±13.85）mmHg，t = 2.78，P = 0.01；动态收缩压：（144.23±7.58）比（157.24±15.65）mmHg，t = 3.75，P＜0.001；动态舒张压：（78.29±9.65）比（83.48±15.18）mmHg，t = 2.44，P = 0.02]。结论 RDN 能降低 ESRD 合并 RHT 患者的血压，病因是 DN 的 ESRD 患者对 RDN 应答率相对较高。

Abstract

Objective To evaluate the feasibility and safety of renal denervation (RDN) in patients with end-stage renal disease (ESRD) and resistant hypertension (RHT). Methods A retrospective analysis was conducted on the baseline and follow-up data of ESRD patients who underwent RDN at the First Affiliated Hospital of Fujian Medical University between December 2017 and December 2024. Based on the etiology of ESRD, the patients were divided into three groups: diabetic nephropathy group (DN group), chronic glomerulonephritis group (CG group), and hypertensive nephrosclerosis group (HE group). RDN was performed using the NavStar pressure monitoring perfusion monopolar ablation catheter (Abbott，USA). A 3D model was constructed using the ENSITE system, and four-quadrant spiral point-by-point ablation was performed from distal to proximal on the main renal arteries and their branches bilaterally. Each ablation site was treated for 40 seconds at a temperature of 40 ℃. The ablation power was set at 8W for renal artery branches and 12W for the main branches. Results A total of 25 ESRD patients were enrolled, including 10 in the DN group, 8 in the CG group, and 7 in the HE group. All patients underwent regular hemodialysis with controlled dry weight. The number of ablation points was 15.04±2.62 for the main branches and 4.68±1.03 for the branch vessels. Fluoroscopy time was (23.64±6.89) minutes, and contrast agent volume was (28.40±8.50) mL. No significant differences were observed among subgroups in terms of impedance, contrast agent volume, or fluoroscopy time before and after ablation. HE group had the least number of ablation points in both main and branch vessels. One case of vascular dissection requiring renal artery stent implantation occurred in the CG group, and one case of pseudoaneurysm occurred in the HE group. The median follow-up duration was (7.90±1.55) months. During follow-up, one patient was lost to follow-up in each the DN and CG groups, and one patient in each the CG and HE groups died due to myocardial infarction. Major adverse cardiovascular events (MACE) occurred in one patient each in the CG and HE groups, both requiring hospitalization for heart failure. Postoperative follow-up was completed in 21 patients. Among them, 15 (71.43%) exhibited a positive response to RDN, including 8 (88.89%) in the DN group, 4 (66.67%) in the CG group, and 3 (50.00%) in the HE group. Compared with preoperative values, office systolic and diastolic blood pressure, as well as 24-hour ambulatory systolic and diastolic blood pressure, showed significant reductions after RDN (office systolic blood pressure: [141.95±10.21] vs [159.88±19.48] mmHg, t = 5.44, P＜ 0.001; office diastolic blood pressure: [79.23±8.69] vs [85.28±13.85] mmHg, t = 2.78, P = 0.01; ambulatory systolic blood pressure: [144.23±7.58] vs [157.24±15.65] mmHg, t = 3.75, P＜0.001; ambulatory diastolic blood pressure: [78.29±9.65] vs [83.48±15.18] mmHg, t = 2.44, P = 0.02). Conclusion RDN can effectively reduce blood pressure in patients with ESRD and RHT. Among the etiological subgroups, patients with DN may represent the most suitable candidates for RDN within the ESRD population.

关键词

终末期肾病 / 难治性高血压 / 去肾神经术

Key words

end-stage renal disease / resistant hypertension / renal denervation

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基金资助

福建省科技创新联合资金项目(2023Y9067)

福建省自然科学基金(2024J01558)

福建省自然科学基金(2024J01516)

福建省科技创新联合资金项目(2024Y9177)

福建省自然科学基金(2023J01609)

代谢性心血管病福建省高校重点实验室开放课题(MCD2026004)