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Hypertension remains a major public health problem and one of the most relevant causes of cardiovascular mortality and morbidity worldwide. Roughly 10% of hypertensive individuals are considered as "resistant" as they are not able to achieve and maintain optimal blood pressure values despite the concurrent use of 3 antihypertensive agents of different classes at optimal doses. As resistant hypertension conveys a higher risk of adverse outcomes, the search for effective treatments to properly manage this condition has progressively surged as a true health priority. The renal nerve plexus plays a central role in regulating arterial blood pressure and renal sympathetic overactivity is a major component in the development and progression of hypertension. On these premises, minimally-invasive catheter based devices for renal nerve ablation have been developed and tested as an alternative treatment for resistant hypertension, but clinical study results have been ambiguous. This review provides a historical perspective on the scientific evidence forming the foundation of renal never ablation from accrued clinical evidence to possible future applications, reaching a tentative conclusion that more research and clinical experience is needed to fully reveal limits and potential indications of this procedure., Competing Interests: The authors state that there are no conflicts of interest to disclose., (© 2019 Bolignano et al. Published by IMR press. All rights reserved.)

The search of alternative methods for improving clinical management and outcomes of individuals affected by resistant hypertension has become a true health priority. In this review, we aimed at providing a timely overview and evidence synthesis on baroreflex activation therapy (BAT) and endovascular baroreflex amplification (EBA), two device-based therapies which rely on the principle of lowering blood pressure by stimulating the carotid baroreflex to decrease the sympathetic and enhance the parasympathetic activity. In resistant forms of arterial hypertension, accruing evidence has confirmed the capacity of these techniques to improve blood pressure control and to reduce the amount of anti-hypertensive therapy at cost of few side effects. Future results from ongoing randomized sham-controlled trials are eagerly awaited to best define the efficacy, safety and durability of effects in the long term before such an invasive approach may be considered as a suitable option in daily clinical practice., Competing Interests: The authors declare no competing interests., (© 2018 Bolignano et al. Published by IMR press. All rights reserved.)

Muscle sympathetic nerve activity (MSNA) has shown that sympathetic activation may occur in essential hypertension (EHT). However, the small sample size of the studies, the heterogeneity of the patients examined, and the presence of confounders represented major weaknesses not allowing to draw definite conclusions. Among the 432 studies identified providing information in EHT on MSNA, 63 were eligible (1216 patients) and meta-analyzed grouping them on the basis of clinically relevant questions: (1) Is MSNA increased in hypertension of mild/moderate-to-severe degree? (2) Does sympathetic activation occur in borderline, white-coat, and masked EHT? (3) Is MSNA related to clinic and ambulatory blood pressure and target organ damage? (4) Are heart rate and venous plasma norepinephrine valuable surrogate markers of MSNA in clinical practice? The results show that MSNA was significantly greater (1.5×; P <0.001) in mild-to-moderate and severe EHT as compared with normotensive controls and that this was the case also in borderline, white-coat, and masked hypertension as well. Interestingly, MSNA was significantly greater in both untreated and treated hypertension ( P <0.001 for both), related to clinic and ambulatory blood pressure ( r =0.67 and r =0.83; P <0.001 for both), inversely related to heart rate ( r =-0.38; P <0.001) and directly to venous plasma norepinephrine ( r =0.28; P <0.001) and left ventricular mass index ( r =0.27; P <0.001). Thus, EHT is a condition characterized by a sustained sympathetic overdrive, whose magnitude is proportional to its clinical severity. This is more clearly manifest when MSNA rather than indirect markers of adrenergic drive, such as heart rate and plasma norepinephrine, are used., (© 2018 American Heart Association, Inc.)

Aims: We evaluated relaxin's behaviour during a haemodialytic session and the effects of its intradialytic variability on blood pressure., Methods: We enrolled 25 patients and evaluated relaxin's levels during a haemodialytic session. We also dosed interdialytic relaxin and enrolled 10 healthy subjects and 16 patients with III stage chronic renal failure as controls., Results: Haemodialyzed patients have relaxin's baseline concentrations higher than healthy controls, but lower than chronic patients. During the treatment, relaxin is removed; it increases again throughout the interdialytic phase. Furthermore, relaxin's pre- haemodialytic concentration positively and significantly correlates with systolic, diastolic, and mean BP; such correlations disappear at the end of the treatment., Conclusion: Relaxin's removal during the treatment may intervene in the pathogenesis of intradialytic hypertension. Hence, relaxin could be not only a new biomarker but also an active player in the intradialytic variations of blood pressure.

Background Hypertension (HTN) is common following renal transplantation and it is associated with adverse effects on cardiovascular (CV) and graft health. Ambulatory blood pressure monitoring (ABPM) is the preferred method to characterize blood pressure (BP) status, since HTN misclassification by office BP (OBP) is quite common in this population. We performed a systematic review and meta-analysis aimed at determining the clinical utility of 24-h ABPM and its potential implications for the management of HTN in this population. Methods Ovid-MEDLINE and PubMed databases were searched for interventional or observational studies enrolling adult kidney transplant recipients (KTRs) undergoing 24-h ABP readings compared with OBP or home BP. The main outcome was the proportion of KTRs diagnosed with HTN by ABPM, home or OBP recordings. Additionally, day–night BP variability and dipper/non-dipper status were assessed. Results Forty-two eligible studies (4115 participants) were reviewed. A cumulative analysis including 27 studies (3481 participants) revealed a prevalence of uncontrolled HTN detected by ABPM of 56% [95% confidence interval (CI) 46–65%]. The pooled prevalence of uncontrolled HTN according to OBP was 47% (95% CI 36–58%) in 25 studies (3261 participants). Very few studies reported on home BP recordings. The average concordance rate between OBP and ABPM measurements in classifying patients as controlled or uncontrolled hypertensive was 66% (95% CI 59–73%). ABPM revealed HTN phenotypes among KTRs. Two pooled analyses of 11 and 10 studies, respectively, revealed an average prevalence of 26% (95% CI 19–33%) for masked HTN (MHT) and 10% (95% CI 6–17%) for white-coat HTN (WCH). The proportion of non-dippers was variable across the 28 studies that analysed dipping status, with an average prevalence of 54% (95% CI 45–63%). Conclusions In our systematic review, comparison of OBP versus ABP measurements disclosed a high proportion of MHT, uncontrolled HTN and, to a lesser extent, WCH in KTRs. These results suggest that HTN is not adequately diagnosed and controlled by OBP recordings in this population. Furthermore, the high prevalence of non-dippers confirmed that circadian rhythm is commonly disturbed in KTRs. [ABSTRACT FROM AUTHOR]

Background Few studies show that ambulatory blood pressure (BP) monitoring (ABPM) is superior to office BP (oBP) measurements to predict target organ damage and cardiovascular (CV) events in kidney transplant recipients (KTRs). We performed a systematic review aimed at determining the potential associations between BP recordings by different methods and renal and CV outcomes in this population. Methods Major medical databases were searched for studies enrolling adult KTRs undergoing 24-h ABPM compared with office or home BP measurements. The main outcomes were associations between different BP recordings and renal and CV outcomes. Additionally, any association between the circadian BP pattern (dipping/non-dipping status) and outcomes was assessed. Results Twenty-two studies (2078 participants) were reviewed. Among 12 studies collecting data on renal endpoints, 10 studies found that BP assessed by ABPM was a stronger predictor of renal function decline, assessed by serum creatinine and/or creatinine clearance or estimated glomerular filtration rate, than traditional office measurements. Twelve studies analysed the relation between different BP recordings and CV target organ damage and reported robust correlations between echocardiographic abnormalities (i.e. left ventricular mass index) and 24-h ABPM, but not with office BPs. Furthermore, 24-h ABPM correlated better than oBP with markers of vascular damage, such as carotid intima-media thickness, diffuse thickening and endothelial dysfunction. Additionally, an abnormal circadian BP pattern (non-dippers and reverse dippers) identified a group of kidney recipients at risk for kidney function loss and CV abnormalities. Conclusions In our systematic review, ABPM reflected target organ damage more closely than oBP in KTRs. Furthermore, an altered circadian BP profile associated with renal and CV target organ damage. [ABSTRACT FROM AUTHOR]

Background. It is the object of debate whether a low or high dialysate sodium concentration (DNa+) should be advocated in chronic haemodialysis patients. In this paper, we aimed at evaluating benefits and harms of different DNa+ prescriptions through a systematic review of the available literature. Methods. MEDLINE and CENTRAL databases were searched for studies comparing low or high DNa+ prescriptions. Outcomes of interest were mortality, blood pressure (BP), interdialytic weight gain (IDWG), plasma sodium, hospitalizations, use of anti-hypertensive agents and intradialytic complications. Results. Twenty-three studies (76 635 subjects) were reviewed. There was high heterogeneity in the number of patients analysed, overall study quality, duration of follow-up, DNa+ and even in the definition of 'high' or 'low' DNa+. The only three studies looking at mortality were observational. The risk of death was related to the plasma-DNa+ gradient, but was also shown to be confounded by indication from the dialysate sodium prescription itself. BP was not markedly affected by high or low DNa+. Patients treated with higher DNa+ had overall higher IDWG when compared with those with lower DNa+. Three studies reported a significant increase in intra-dialytic hypotensive episodes in patients receiving low DNa+. Data on hospitalizations and use of anti-hypertensive agents were sparse and inconclusive. Conclusions. There is currently no definite evidence proving the superiority of a low or high uniform DNa+ on hard or surrogate endpoints in maintenance haemodialysis patients. Future trials adequately powered to evaluate the impact of different DNa+ on mortality or other patient-centred outcomes are needed. [ABSTRACT FROM AUTHOR]