Renal Denervation in 2025: A Practical, Evidence‐Based Option for Resistant and Uncontrolled Hypertension - Tahminakhan123/healthpharma GitHub Wiki

Renal denervation (RDN) has re-emerged as a viable, catheter-based adjunct for lowering blood pressure (BP) in selected patients with sustained, uncontrolled hypertension despite medical therapy. The procedure aims to reduce renal sympathetic efferent and afferent signaling via endovascular ablation of nerves along the renal artery, producing durable reductions in sympathetic tone and systemic BP.

Why RDN again?

A decade of incremental trial improvements culminated in well-designed, sham-controlled studies showing clinically meaningful BP reductions. Modern RDN systems (radiofrequency and endovascular ultrasound) employ more consistent multiquadrant ablation patterns and improved procedural protocols; high-quality randomized data—such as RADIANCE and SPYRAL program trials—demonstrate reductions in ambulatory and office BP in both on- and off-medication settings. These data have shifted practice guidelines to acknowledge Renal denervation (RDN) as a potential adjunct in selected patients.

Patient selection and evaluation are critical. Candidates typically include adults with sustained elevated BP despite optimized guideline-directed therapy (or those intolerant to multiple agents). Confirmation of true hypertension using 24-hour ambulatory BP monitoring (ABPM) or home BP monitoring is recommended to exclude white-coat or masked hypertension. Secondary causes (renal artery stenosis, endocrine causes) must be excluded before considering RDN. Multidisciplinary assessment—including hypertension specialists, interventional cardiologists or radiologists, and nephrologists—is best practice.

Efficacy and durability

Randomized sham-controlled trials and longer-term follow-ups show average systolic BP reductions that are clinically meaningful (frequently in the range of ~5–10 mmHg ambulatory systolic BP depending on population and trial). Importantly, longer follow-up analyses from SPYRAL and related cohorts suggest persistent BP lowering through 12–24 months in many patients, with some trials reporting sustained effects when medication regimens remain stable. These reductions translate into estimated reductions in cardiovascular risk when combined with standard therapy.

Safety profile

RDN is generally well tolerated. Major complications—access-site vascular injury, renal artery dissection, or clinically relevant decline in renal function—are uncommon when the procedure is performed by experienced operators with appropriate imaging and technique. Peri-procedural imaging and follow-up (duplex, CTA/MRA when indicated) help identify vascular issues early. As with any invasive therapy, patient counselling should cover potential benefits, risks, and the possibility that BP lowering may be modest and require ongoing antihypertensive medication.

Guideline position and practical implementation

The 2024–2025 guideline cycle increasingly recognizes RDN as an adjunct option (Class IIb in some recommendations) for patients with uncontrolled hypertension despite optimal therapy or for those who cannot tolerate medications. Implementation requires institutional protocols (patient selection, operator credentialing, follow-up pathways, registry participation) and shared decision-making. Centers should capture outcomes in registries to further refine long-term effectiveness and safety.

Future directions

Ongoing trials are refining which phenotypes (e.g., therapy-resistant, poor adherence, sympathetic overactivity markers) derive the largest benefit, exploring combination strategies with lifestyle and pharmacologic care, and optimizing device technology to increase nerve targeting while minimizing risk. As the evidence base grows, RDN is positioned as a pragmatic adjunct in a precision-medicine approach to hypertension care.