Denerwacja nerek – szansa na opanowanie nadciśnienia opornego

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Jak mówią dane epidemiologiczne, ok. 9 milionów dorosłych Polaków choruje na nadciśnienie tętnicze. Ilu z nich spełnia definicję nadciśnienia opornego – nie reagującego na terapię jednocześnie 3 lekami hipotensyjnymi, trudno jednoznacznie określić. Ale wobec coraz większego rozpowszechnienia otyłości, cukrzycy i idącej z nią w parze przewlekłej choroby nerek, liczba ta na pewno nie jest mała. W obliczu porażki farmakoterapii, szansą na kontrolę ciśnienia tętniczego (RR) u takich pacjentów jest zabieg denerwacji nerek.

Pomysł walki z nadciśnieniem tętniczym poprzez chirurgiczną ingerencję w układ współczulny narodził się jeszcze przed II wojną światową, a więc zanim opracowano pierwsze leki hipotensyjne. U jego podstawy legło proste założenie – ograniczenie impulsacji adrenergicznej doprowadzi do zwiększenia przepływu nerkowego, a co za tym idzie do zmniejszenia retencji sodu i wody. Splanchnicektomia, czyli wycięcie niemal całego pnia współczulnego, którą wtedy stosowano, prowadziła co prawda do obniżenia ciśnienia,  ale efekt terapeutyczny był okupiony wieloma działaniami ubocznymi. Impotencja, omdlenia ortostatyczne, zaburzenia perystaltyki i wydzielania kwasu żołądkowego występujące u chorych po zabiegu doprowadziły do zaprzestania jego wykonywania. Jednak sam pomysł chirurgicznego zmniejszenia wpływu układu współczulnego na nerki, pozostał żywy w umysłach naukowców, czego efektem było stworzenie w ostatnich latach cewnika Symplicity, pozwalającego na przerywanie włókien autonomicznych biegnących w przydance tętnic nerkowych. Prąd o częstotliwości radiowej emitowany z narzędzia umieszczonego wewnątrz naczynia przerywa trwale przewodnictwo nerwowe, nie uszkadzając przy tym w sposób istotny ściany tętnicy, a sam zabieg jest minimalnie obciążający dla chorego. Oczywiście nie ma też występujących po splanchnicektomii powikłań narządowych.

Rezultaty przeprowadzonych dotychczas badań klinicznych, dotyczących wpływu denerwacji nerek na kontrolę ciśnienia tętniczego, wyglądają obiecująco. Podczas niedawnego kongresu w Monachium naukowcy z kilku ośrodków przedstawili niezależnie wyniki wykonanych przez siebie zabiegów i wszystkie potwierdzały jednoznacznie korzystny efekt płynący z uszkodzenia włókien współczulnych zaopatrujących nerki. Zaprezentowano między innymi nowe dane pochodzące z przedłużonej obserwacji pacjentów włączonych do programu Symplicity HTN-2, którego wcześniejsze konkluzje doczekały się publikacji w Lancecie [1].  Protokół tego badania zakładał losowe przydzielenie pacjentów do dwóch grup – jednej leczonej inwazyjnie i jednocześnie farmakologicznie, i drugiej przyjmującej tylko standardowe leki obniżające ciśnienie. Co uderzające, początkowe ciśnienie tętnicze chorych włączonych do badania wynosiło przed jego rozpoczęciem średnio ok. 180/100 mmHg i to mimo przyjmowania przeciętnie 5 (!) leków obniżających RR. Po denerwacji nerek i 18 miesiącach obserwacji, podczas której kontynuowano leczenie preparatami hipotensyjnymi pacjenci z grupy badanej uzyskali spadek ciśnienia o -32/-12 mmHg. W tym samym czasie u  chorych w grupie kontrolnej, poddawanych jedynie farmakoterapii, nie odnotowano poprawy. Co więcej, już po 6 miesiącach ponad 80% osób po denerwacji nerek odniosło korzyść w postaci istotnego (o minimum 10 mmHg) obniżenia RR. Jednocześnie nie zaobserwowano żadnego przypadku istotnego powikłania okołozabiegowego.

Wyniki badań dają chorym z nadciśnieniem opornym nadzieję na lepszą kontrolę RR, a tym samym spowolnienie rozwoju powikłań narządowych oraz wydłużenie życia. Denerwacja nerek ma szansę w przyszłości stać się standardowo wykonywaną procedurą, być może nie tylko u tej grupy pacjentów.

1. Symplicity HTN-2 Investigators et al., Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomised controlled trial. Lancet, 2010; 376:1903-1909.



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  24. A month later I had a right adrenalectomy. [url=http://eudrg.com]pastillas cialis barato[/url] Quick Hit Descriptive study designs case reports case series crosssectional stud ies suggest or generate hypotheses.Vorvick MD Medical Director MEDEX Northwest Division of Physician Assistant Studies University of Washington School of Medicine and Susan Storck MD FACOG Chief Eastside Department of Obstetrics and Gynecology Group Health Cooperative of Puget Sound Redmond Washington Clinical Teaching Faculty Department of Obstetrics and Gynecology University of Washington School of Medicine.They may be either malignant capable of invasion and spread to surrounding or more distant sites or benign noninvasive and not spreading to other sites.dysthymiaHealth Solutions Ebix Inc.Textbook of Family Medicine. [url=http://tadalafilfor.com]compare generic cialis prices[/url] The treatment was often carried out by surgeons and barbersurgeons who combined shaving and haircutting with basic surgical work see pp.However the question of why will always come second to whetherand it is likely to be academic to anyone who benefits from these hitherto mysterious arts.Quick Hit CCK is the hormone that relaxes the sphincter of Oddi and contracts the gallbladder.Chronic thyroiditis Hashimotos diseaseEmail this page to a friendShare on facebookShare on twitterBookmark SharePrinterfriendly version Chronic thyroiditis is swelling inflammation of the thyroid gland that often results in reduced thyroid function hypothyroidism.If illness continues for a longer period e.The ED portion of the searches spanned the years from when the final literature search for the Report was completed to February [url=http://buydapoxetinerxus.com]buy priligy[/url] Check routine lab oratory values to document anemia and the patients MCV should be high.F r cos sinSee Clinical Pearl..ADDITIONAL SUFFIXES AND DIGESTIVE SYSTEM TERMINOLOGY Common bile duct Gallstone Gallbladder Endoscope A B FIGURE A Endoscopic retrograde cholangiopancreatography ERCP showing choledocholithiasis in a patient with biliary colic pain. [url=http://buytadalafil20mgprice.com]cialis for sale[/url] CLINICAL PROCEDURES cryosurgery Use of subfreezing temperature achieved with liquid nitrogen application to destroy tissue.Cochrane Database Syst Rev.Examples of purging are selfinduced vomiting and the misuse of laxatives or enemas.Bone marrow failure leading to pancytopenia anemia neutropenia thrombocytopeniaVarious methods of administering drugs are Oral Administration. [url=http://edrxnewmedfor.com]vardenafil in osterreich erhaltlich[/url] Physical examination reveals crackles in bilateral lower lobes..Stem cell research can also provide more ways of testing potential medicinal drugs and toxic chemicals.Other protective factors include having a high reward that matches high demand and having a high social status.

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[url=http://dapoxetinefast.com]cialis with dapoxetine[/url] id Major unconscious part of the personality energy from instinctual drives and desires.The classroom instructors listed on pages xvixvii extensively and carefully reviewed the text and I have listened to their comments which are integrated into this new edition.More recently pharmacotherapies such as SSRIs and antidepressants have been used.Pronunciation Guide a as in a pe a as in a pple e as in e ven e as in e very i as in i ce i as in i nterest o as in o pen o as in p o t u as in u nit u as in u nder Vocabulary and Terminology TERM PRONUNCIATION MEANING adaptive immunity a D A Pt i v i M U n i t e adenoids A D e noydz anaphylaxis a n a f a L A Ks i s antibody A Nt i b o d e antigen A Nt i j e n asplenia a SPL E N e a autoimmune disease awt o i M U N d i Z E Z axillary nodes A KS i l a r e n o dz B cell B s e l cellmediated immunity s e l m e d e A t e d i M U N i t e cervical nodes S E Rv i kl n o dz complement system C O Mpl e m e nt S i St e m cytokines S I t o k i nz cytotoxic T cell s i t o T O Ks i k T s e l dendritic cell d e nDR I t i k s e l helper T cell H E Lp e r T s e l humoral immunity H U m e r a l i mM U N i t e hypersplenism h i p e rSPL E N i zm immunity i mM U N i t e immunoglobulins i m u n o GL O B u l i nz immunosuppression i m u n o s u PR E sh u n immunotherapy i m u n o TH E R a p e LYMPHATIC AND IMMUNE SYSTEMS TERM PRONUNCIATION MEANING inguinal node I NGgw i n a l n o d interferons i nt e rF E R o nz interleukins i nt e rLOOk i nz interstitial uid i nt e rST I SH a l FLOO i d lymph l i mf lymphadenitis l i mf a hd e N I t i s lymphadenopathy l i mf a d e N O P a hth e lymph capillaries l i mf K A P i l a r e z lymphedema l i mf e D E m a lymph node l i mf n o d lymphocytes L I Mf o s i tz lymphocytosis l i mf o s i T O s i s lymphocytopenia l i mf o s i t o P E n e a lymphoid organs L I Mfoid O Rg a nz lymphopoiesis l i mf o poy E s i s lymph vessel l i mf V E S e l macrophage M A Kr o f a j mediastinal nodes m e d e a sT I n a l n o dz mesenteric nodes m e s e nT E R i k n o dz monoclonal antibody m o n o KL O n a l A Nt i b o d e natural immunity N A t u r a l i mM U n i t e paraaortic nodes p a r a a O Rt i k n o dz plasma cell PL A Zm a s e l right lymphatic duct r i t l i mF A t i k d u kt spleen spl e n splenectomy spl e N E Kt o m e splenomegaly spl e n o M E G a l e suppressor T cell s u PR E s o r T s e l T cell T s e l thoracic duct th o R A s i k d u kt thymectomy th i M E Kt o m e thymus gland TH I m u s gl a nd tolerance T O L e r a ntz tonsils T O Ns i lz LYMPHATIC AND IMMUNE SYSTEMS TERM PRONUNCIATION MEANING toxic T O Ks i k toxin T O Ks i n vaccination v a ks i N A sh u n vaccine v a kS E N Pathology and Laboratory Tests TERM PRONUNCIATION MEANING acquired immunodeciency syndrome a KW I RD i m u n o d e F I SH e ns e S I Ndr o m allergen A L e rj e n allergy A L e rj e atopy A T o p e CD cell CD P O S i t i v s e l ELISA e L I z a Hodgkin disease H O Jk i n d i Z E Z human immunodeciency virus H U m a n i m u n o d e F I SH e ns e V I r u s immunoelectrophoresis i m u n o e l e ktr o ph o r E s i s Kaposi sarcoma K A p o s e or k a P O Ss e s a rK O m a lymphoma l i mF O m a multiple myeloma M U LT i pl m i e L O m a nonHodgkin lymphoma n o nH O Jk i n l i mF O ma opportunistic infections o pp o rt u N I St i k i nF E Ksh u nz protease inhibitors PR O t e a s i nH I B i t o rz reverse transcriptase inhibitors severe combined immunodeciency disease r e V E RS tr a nsSCR I PT a z i nH I B i t o rz s e V E R k o mB I ND i m u n o d e F I SH e ns e d i Z E Z thymoma th i M O m a viral load test v i r a l l o d t e st wasting syndrome W A ST i ng S I Ndr o m Western blot W E St e rn bl o t LYMPHATIC AND IMMUNE SYSTEMS REVIEW SHEET Write the meaning of the word parts in the spaces provided. 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