肾脏去交感神经支配术在心衰治疗中的作用

The Role of Renal Sympathetic Denervation in the Treatment of Heart Failure

心脏和肾脏通过一系列神经体液调节机制相互作用,这种作用维持正常状态下的循环稳态。然而,调节机制在充血性心衰时变的异常,充血性心衰患者中,肾功能不全常常会进一步进展。肾交感传出神经激活引起肾素释放,钠水潴留,以及肾血流量减少,都是充血性心衰时肾脏表现。由肾脏部分调节释放的血管紧张素II水平增加,作用于中枢神经系统后可增加全身交感神经活性,临床上肾脏交感神经活性可通过去甲肾上腺素分泌进行评估,充血性心衰时去甲肾上腺素分泌增加提示预后不良。除传出交感神经激活外,心衰时肾脏传入神经的激活可反射性引起交感神经活性的增加,进而引起外周血管阻力增加、血管重塑、心室重塑及左室功能障碍。在心衰动物模型中,外科肾脏去交感神经支配术可以改善肾脏和心室功能,但有创性操作过程以及相关并发症限制了其应用。近期出现的经导管射频消融去肾脏交感神经支配术可特异性阻断肾传出、传入神经,已成功应用于顽固性高血压的治疗。目前评估心衰患者肾脏去交感神经支配术安全性及有效性的临床试验正在进行中。

The heart and kidney interact in terms of neurohumoral regulatory mechanisms,and this helps to maintain circulatory homeostasis.However,normal mechanisms become inappropriate in the setting of congestive heart failure（CHF）,and significant renal dysfunction often develops in CHF patients.Activation of renal sympathetic efferent nerves causes renin release,sodium and water retention,and reduced renal blood flow,all of which were the renal manifestations of CHF.An increase in plasma levels of angiotensin II that is mediated in part by renal sympathetic activation has an effect on the central nervous system to further increase global sympathetic tone.In addition to efferent sympathetic activation,activation of renal sensory nerves in CHF may cause a reflex increase in sympathetic tone that contributes to elevated peripheral vascular resistance and vascular remodeling as well as left ventricular remodeling and dysfunction.In animal models of heart failure,surgical renal denervation has been shown to improve both renal and ventricular function but the invasive nature of this approach and its associated complications has limited its appeal.Recently,a novel catheter-based device has recently been used in the treatment of resistant hypertension.Meanwhile,ongoing clinical trials are investigating the safety and efficacy of renal denervation in patients with CHF.