Effect of renal denervation in chronic kidney disease: a systematic review, time-stratified meta-analysis and meta-regression of blood pressure and renal outcomes

Hypertension in chronic kidney disease (CKD) is frequently resistant to pharmacologic therapy, with sympathetic overactivity contributing to both elevated blood pressure (BP) and renal disease progression. Renal denervation (RDN) targets renal sympathetic nerves and may provide dual benefits by lowering BP and improving renal outcomes. However, concerns regarding renal safety have limited its use in CKD. This meta-analysis evaluates the efficacy and renal safety of RDN in hypertensive patients with CKD. A systematic search was conducted across PubMed, Cochrane, Embase, and Scopus for RCTs and observational studies. Outcomes included changes in office systolic blood pressure (OSBP) and diastolic blood pressure (ODBP), 24-h ambulatory systolic blood pressure (ASBP) and diastolic blood pressure (ADBP), estimated glomerular filtration rate (eGFR), serum creatinine, and urine albumin-to-creatinine ratio (UACR) at 3, 6, 12, and 24 months. Pooled mean differences (MD) were calculated using a random-effects model. Nineteen observational studies were included. OSBP reductions were sustained from 3 months (MD: − 24.33 mmHg, 95% CI − 40.12 to − 8.55) to 24 months (MD: − 18.63 mmHg, 95% CI − 27.04 to − 10.22). ASBP (MD: − 8.20 mmHg, 95% CI − 11.64 to − 4.77) and ADBP (− 3.99 mmHg, 95% CI − 6.05 to − 1.93) also declined significantly at 24 months. Serum creatinine and UACR did not significantly worsen through 24 months, although a modest but statistically significant decline in eGFR was observed at 24 months. In conclusion, RDN was associated with significant and sustained reductions in both office and ambulatory BP in patients with CKD, with renal function fairly preserved over the same period. These findings should be considered hypothesis-generating given the overall low certainty of evidence. Adequately powered, sham-controlled RCTs in CKD populations are warranted to confirm efficacy and long-term renal safety. Trial registration PROSPERO Registration: CRD420261278629