Zusammenfassung
Wenig neue Methoden der antihypertensiven Therapie haben in den letzten Jahren zu so viel Diskussion geführt wie die sog. renale Denervierung der sympathischen Nervenfasern. Die Stimulation des Sympathikus beeinflusst die Funktion der Niere durch die Freisetzung von Renin, eine gesteigerte Aufnahme von NaCl und durch Vasokonstriktion der renalen Widerstandsgefäße. Diese Mechanismen steigern den Blutdruck und sollen durch die Ablation der Nervenfasern blockiert werden. Die Entwicklung einer sicheren Ablationsmethode beim Menschen in den letzten Jahren hat dieses Verfahren klinisch einsetzbar gemacht. In den ersten klinischen Studien hat dieses Verfahren beeindruckende Blutdruckabfälle gezeigt. Diese therapeutische Wirksamkeit war in diesen Studien auch noch nach Jahren nachweisbar. Darüber hinaus konnten positive Wirkungen auf andere, durch den Sympathikus verursachte, Probleme wie den Glukosemetabolismus und die Schlafapnoe nachgewiesen werden. Allerdings zeigten sich bereits in den ersten kontrollierten Untersuchungen teilweise „therapieresistente“ Patienten. In der ersten großen randomisierten, doppelblind durchgeführten Studie (Simplicity-3) konnte keine therapeutische Wirkung der Nervenablation auf den Blutdruck nachgewiesen werden. Dem stehen Registerdaten und unkontrollierte Befunde mit einer sehr ausgeprägten therapeutischen Wirksamkeit entgegen. Erklärungen für den negativen Ausgang von Simplicity-3 sind vielfältig und reichen von Compliance bis zum Versagen der Methode in dieser Studie. Es wird notwendig sein, die „ansprechbaren“ Patienten zu definieren, diese mit geeigneten diagnostischen Methoden zu charakterisieren und diese dann in kontrollierte Studien einzuschleusen. Bis dahin hat das Verfahren der renalen Ablation einen experimentellen Charakter.
Abstract
Catheter-based renal nerve ablation can lower blood pressure (BP) in hypertensive patients. The concept is based on solid physiological studies suggesting that efferent and afferent renal nerves contribute to arterial hypertension. The preliminary results on the efficacy and safety of catheter-based renal nerve ablation on BP control in resistant hypertension have been encouraging; however, these studies were uncontrolled. In several small studies it was observed early that most patients can be controlled by pharmaceutical treatment and only a few patients respond to ablation therapy. A large prospective trial with a control group (sham treatment) was therefore necessary. The Simplicity-3 trial fulfilled these criteria. More than 600 patients were successfully studied and in March 2014 the results were published. No significant differences between the two groups were observed, one treated with renal nerve ablation and the other group controlled only by medication. These results are in contrast to the previous (uncontrolled) studies and observations from a worldwide registry. Several explanations have been put forward to explain these results. Important are (1) compliance, i.e. patients taking their medication during the study and also (2) inexperience with the method in small centers. Simplicity-3 has put a halt on using renal denervation in most countries. It is now important to find out why the method only works in some patients, what the criteria to use it are and to define a patient group where renal denervation is useful as a therapeutic method to treat patients with hypertension.
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Interessenkonflikt. H. Haller und F. Limbourg geben an, dass kein Interessenkonflikt besteht. J. Menne hat die Firma CVRx als Interessenkonflikt angegeben. B.M. Schmidt hat Honorare von den Firmen Novartis, Daichii Sankyo und Berlin-Chemie Menarini erhalten,
Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.
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Haller, H., Menne, J., Limbourg, F. et al. Renale Denervierung und Hypertonie. Nephrologe 9, 350–356 (2014). https://doi.org/10.1007/s11560-014-0874-0
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DOI: https://doi.org/10.1007/s11560-014-0874-0