肾脏去神经化在心力衰竭治疗中的研究进展

Research Progress of Renal Denervation in Patients with Congestive Heart Failure

生理情况下,心脏和肾脏在血流动力学和神经激素等调节中相互作用,对于循环系统的稳态维持起重要作用。但在充血性心力衰竭的病理情况下,心脏和肾脏之间存在明显的调节紊乱。首先,急性失代偿性心力衰竭的患者住院治疗的研究结果证明其有一定程度的肾脏失调。其次,慢性充血性心力衰竭时肾脏交感神经系统也起到重要作用:肾脏交感纤维活性增强可导致肾素的释放、钠水潴留、肾血流的降低、血管阻力增加、左心室重塑、左心功能失调等。众所周知,肾脏交感神经切除术可以减低血压和改善心脏功能,但是由于有创的手术方式限制了其应用。过去两年间,随着新的导管消融肾脏去神经化技术的日益完善,其有望成为治疗高血压病和心力衰竭的手段。在此,本文综述了心力衰竭时肾脏交感传入神经和传出神经的发病机理,对目前进行的经导管肾脏去神经化治疗慢性心力衰竭的基础及临床试验进行安全性及有效性评价。提示我们经导管肾脏去神经化有望成为心力衰竭治疗的新靶点。

Interaction between the heart and kidney in the field of hemodynamics and regulation of neurohumoral contributes to maintain circulatory homeostasis under normal conditions. Nevertheless, the normal regulatory mechanisms are inappropriate at the beginning of congestive heart failure. Data from surveys showed that in-patients for acute decompensated congestive heart failure（CHF）have some degree of renal insufficiency. The renal nerves play a pivotal role in the renal dysfunction that occurs in CHF. The activation of renal sympathetic efferent nerves caused by congestive heart failure can not only lead to rennin release, sodium and water retention,,reduced renal blood blow, but also elevate peripheral vascular resistance, increase left ventricular remodeling and resulted in its dysfunction. Evidence from the animal models of heart failure demonstrates that surgical renal denervation has been proved to improve renal and ventricular function, expecially for blood pressure lowering and improvement of left ventricular function. However, the invasive nature of this approach and its associated complication may limit its applicability. Recently, a catheter-based renal sympathetic denervation has been shown to interrupt both efferent and afferent renal nerves, and widely used in the treatment of hypertension and heart failure. In this review, we update the activation of efferent and afferent renal nerve activation in heart failure, together with the comprehensive review, of relevant experimental models and clinical trials. These results suggest that a catheter-based renal denervation may be a novel target treatment for CHF patients.