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despite the use of combinations of multiple anti-hypertensive drugs at appropriate doses&#46;</p><p class="elsevierStylePara">In recent years&#44; the gamut of complementary non-pharmacological treatment alternatives has expanded&#46; One of these alternatives&#44; endovascular sympathetic denervation of the afferent and efferent renal sympathetic nerves &#40;renal sympathetic denervation &#91;RSDN&#93;&#41;&#44;<span class="elsevierStyleSup">5</span> presents a rational basis for treating refractory AHT<span class="elsevierStyleSup">6</span> and significantly contributes to increasing the effects of anti-hypertensive medication and improves blood pressure control in these patients&#46;<span class="elsevierStyleSup">7&#44;8</span> This makes RSDN a cost-effective and appropriate therapeutic measure&#46;<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara">Here&#44; we present the case of a patient diagnosed with resistant AHT&#44; treated with seven different anti-hypertensive drugs&#44; and with a registry of 24-hour BP measurements &#62;140&#47;90mm Hg&#46; Due to the inability to reach target BP levels&#44; radiofrequency ablation RSDN was administered&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">CASE REPORT</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Our patient was a 55-year-old male who sought care for the first time in our AHT and vascular risk unit due to poor control of BP levels in March 2010&#46; Relevant family history included&#58; mother on renal replacement therapy due to chronic renal failure of unknown origin&#44; and known AHT in the patient that was first observed incidentally in a routine medical examination and had been followed by primary care since 2002&#46; The patient was a smoker until February 2010&#44; but reported that he did not ingest major quantities of salt&#44; alcoholic beverages&#44; or other substances or drugs that could interfere with BP or anti-hypertensive medications&#46; An initial physical examination revealed a BP of 190&#47;110 mm Hg&#44; and a mean BP over 24 hours &#40;ABPM&#41; of 169&#47;109mm Hg&#44; with a non-dipper profile&#46;<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara">Complementary tests revealed&#58; haematocrit&#58; 39&#46;6&#37;&#59; haemoglobin&#58; 13&#46;1g&#47;dl&#59; glycaemia&#58; 102mg&#47;dl&#59; creatinine&#58; 0&#46;9mg&#47;dl&#59; uric acid&#58; 5&#46;9mg&#47;dl&#59; total cholesterol&#58; 149mg&#47;dl&#59; triglycerides&#58; 250mg&#47;dl&#59; HDL cholesterol&#58; 23mg&#47;dl&#59; LDL cholesterol&#58; 104mg&#47;dl&#59; sodium&#58; 146mmol&#47;l&#59; and potassium&#58; 4&#46;1mmol&#47;l&#46; Urinary sediments were normal&#44; with microalbuminuria at 42mg&#47;24 hours&#44; and no toxic substances present&#46; Other laboratory results included&#58; thyrotropin-releasing hormone &#40;TRS&#41;&#58; 1&#46;43mIU&#47;ml&#59; plasma renin activity &#40;PRA&#41;&#58; 0&#46;26ng&#47;ml&#47;min&#59; aldosterone&#58; 264pg&#47;ml&#59; and catecholamine levels within normal range&#46; A renal Doppler-ultrasound was normal&#44; and an electrocardiogram revealed sinus rhythm with signs of left ventricular hypertrophy&#46;</p><p class="elsevierStylePara">Since the PRA&#47;aldosterone ratio was &#62;100&#44; we started treatment with spironolactone&#44; which was not very effective&#46; Two months later &#40;June 2010&#41;&#44; the patient required the prescription of 5 anti-hypertensive drugs&#44; despite which the treatment objectives were still not reached&#46; As such&#44; he was hospitalised for the control of BP&#44; and to evaluate compliance with treatment and the possibility of secondary causes&#46; After an exhaustive evaluation that included new measurements of specific hormone levels&#44; with catheterisation of the renal arteries and scintigraphy with metaiodobenzylguanidine &#40;MIBG&#41; and I-cholesterol&#44; secondary causes were ruled out&#46;</p><p class="elsevierStylePara">Before deciding on administering RSDN&#44; the patient required a total of 10 hospitalisations due to hypertensive emergencies&#44; in which resistance to treatment was again confirmed&#46; Given the inability to control BP levels&#44; and after ruling out possible contraindications for administering RSDN &#40;Figure 1&#41;&#44;<span class="elsevierStyleSup">2&#44;3</span> in January 2012&#44; RSDN was applied through a femoral approach after prior monitoring and premedication&#44; using the recommended protocols&#46; At this point&#44; the patient had grade 3 AHT with signs of target organ damage&#58; left ventricular hypertrophy &#40;LVH&#41;&#44; grade 2 hypertensive retinopathy&#44; and microalbuminuria&#44; and was receiving treatment with&#58; telmisartan&#47;amlodipine at 80&#47;10mg 1&#47;12 hours&#44; aliskiren at 300 mg 1&#47;24 hours&#44; eplerenone at 50mg 1&#47;12 hours&#44; doxazosin at 8mg 1&#47;8 hours&#44; hydrochlorothiazide at 25mg 1&#47;24 hours&#44; and carvedilol at 25mg 1&#47;12 hours&#46;</p><p class="elsevierStylePara">RSDN was applied without complication &#40;Figure 2&#41;&#59; we decided not to treat the left inferior renal polar artery&#44; since the minimum required diameter was not reached&#44; and we observed a left renal artery spasm in the immediate post-procedure radiological control &#40;Figure 3&#41;&#44; which was resolved by injecting nitroglycerin&#44; and for which we decided to start anti-platelet treatment with triflusal&#46;</p><p class="elsevierStylePara">The evolution of BP values following the procedure is described in the Table&#46; Three months after the procedure&#44; mean 24-hour systolic and diastolic BP values had decreased by 22mm Hg&#44; with no significant modification in heart rate&#46; No immediate complications were produced&#44; and the patient has not required further hospitalisations&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">AHT refractory to medical treatment implies a global increase in cardiovascular risk&#44; incurring greater morbidity and mortality rates and economic costs&#46;<span class="elsevierStyleSup">1&#44;2</span> In the small percentage of these patients in which BP control is not reached using anti-hypertensive treatment&#44; RSDN can be a safe and effective treatment option&#46; However&#44; the application of this technique must be preceded by an exhaustive confirmation of true resistance to treatment &#40;through ABPM and evaluation of compliance with treatment&#41; and the presence of target organ damage&#46;<span class="elsevierStyleSup">3</span> In this sense&#44; our patient was an appropriate candidate for this procedure&#44; as he had ABPM-confirmed grade 3 AHT and target organ damage &#40;hypertensive retinopathy&#44; LVH&#44; and microalbuminuria&#41;&#44; with 7 anti-hypertensive drugs&#44; 10 hospitalisations&#44; and yet still deficient control of BP values&#46;</p><p class="elsevierStylePara">In the editorial of this issue of <span class="elsevierStyleItalic">Nefrolog&#237;a</span>&#44; the rational basis for the use of RSDN as a treatment alternative in severe cases of refractory hypertension is concisely described&#46;<span class="elsevierStyleSup">3</span> In short&#44; the concrete indications for this procedure involve sympathetic hyperactivity patients that decisively contributes to the maintenance of high blood pressure values and the production of target organ damage&#46;</p><p class="elsevierStylePara">The endovascular procedure is not particularly difficult&#44; although it always requires prior evaluation of renal anatomy&#44; since the probability of anatomical contraindications is high &#40;10&#37;-15&#37;&#41;&#44; given the multiple possible renal anatomical variants and the possibility of stenosis&#44; which would represent contraindications&#46;<span class="elsevierStyleSup">2&#44;3</span> In our patient&#44; the left inferior renal polar artery was left untreated due to a diameter &#60;4mm&#46; Apart from these considerations&#44; the technique offers no special difficulty&#44; as in our case&#44; with only minimal rates of secondary side effects &#40;&#60;5&#37;&#41;&#44;<span class="elsevierStyleSup">2&#44;7&#44;8</span> usually in the form of transitory local pain when the procedure is carried out&#46;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">The results obtained in our case &#40;mean decrease in BP of 22mm Hg&#41; reflect the results from the Simplicity HTN-1<span class="elsevierStyleSup">7</span> and Simplicity HTN-2<span class="elsevierStyleSup">8</span> studies&#44; where the mean reduction in BP was similar&#44; and even increases over time during follow-up&#46;<span class="elsevierStyleSup">2&#44;3</span> We still have yet to confirm whether the decrease in BP is associated with regression of target organ damage&#46;</p><p class="elsevierStylePara">To conclude&#44; larger randomised studies with longer follow-up periods are needed to address several unanswered questions regarding this technique&#46;<span class="elsevierStyleSup">3</span> However&#44; RSDN appears to be an effective and safe method for producing better control of BP in severe cases of hypertension refractory to multiple pharmacological treatments at appropriate doses&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors have no conflicts of interest to declare&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11573&#95;16025&#95;35651&#95;en&#95;f1&#95;11573&#46;jpg" class="elsevierStyleCrossRefs"><img src="11573_16025_35651_en_f1_11573.jpg" alt="Angio-CAT scan before RSDN&#46; Left inferior renal polar artery "></img></a></p><p class="elsevierStylePara">Figure 1&#46; Angio-CAT scan before RSDN&#46; Left inferior renal polar artery </p><p class="elsevierStylePara"><a href="grande&#47;11573&#95;16025&#95;35652&#95;en&#95;f2&#95;11573&#46;jpg" class="elsevierStyleCrossRefs"><img src="11573_16025_35652_en_f2_11573.jpg" alt="Left RSDN"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Left RSDN</p><p class="elsevierStylePara"><a href="grande&#47;11573&#95;16025&#95;35653&#95;en&#95;f3&#95;11573&#46;jpg" class="elsevierStyleCrossRefs"><img src="11573_16025_35653_en_f3_11573.jpg" alt="Left renal artery spasm following the procedure"></img></a></p><p class="elsevierStylePara">Figure 3&#46; Left renal artery spasm following the procedure</p><p class="elsevierStylePara"><a href="grande&#47;11573&#95;16025&#95;35654&#95;en&#95;t1&#95;11573&#46;jpg" class="elsevierStyleCrossRefs"><img src="11573_16025_35654_en_t1_11573.jpg" alt="Evolution of clinical and laboratory parameters following the procedure"></img></a></p><p class="elsevierStylePara">Table 1&#46; Evolution of clinical and laboratory parameters following the procedure</p>"
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        "resumen" => "<p class="elsevierStylePara">A pesar de los progresos en el tratamiento farmacol&#243;gico de la hipertensi&#243;n arterial &#40;HTA&#41; y el empleo de m&#250;ltiples f&#225;rmacos antihipertensivos&#44; un peque&#241;o pero significativo porcentaje de los pacientes con HTA refractaria severa verdadera contin&#250;a sin alcanzar su objetivo de control tensional&#46; En estos casos&#44; la denervaci&#243;n simp&#225;tica renal &#40;DNSR&#41; parece mostrarse como un m&#233;todo seguro y eficaz para aquellos pacientes hipertensos severos refractarios al tratamiento farmacol&#243;gico m&#250;ltiple&#46; Presentamos el caso de un paciente de 52 a&#241;os de edad diagnosticado de HTA esencial refractaria a tratamiento con 7 f&#225;rmacos antihipertensivos&#46; Tras 10 ingresos hospitalarios sin conseguir un adecuado control de las cifras de presi&#243;n arterial&#44; decidimos plantear la DNSR como coadyuvante al tratamiento m&#233;dico&#46; El procedimiento se realiz&#243; sin complicaciones a corto y medio plazo&#44; consigui&#233;ndose una mejor&#237;a significativa de las cifras tensionales&#44; con el objetivo de disminuir su riesgo vascular global&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara">Despite advances in the pharmacological treatment of arterial hypertension &#40;AHT&#41; and the use of multiple antihypertensive drugs&#44; a small but significant percentage of true severe refractory arterial hypertension patients are still not reaching their target blood pressure&#46; In these cases&#44; renal sympathetic denervation &#40;RSD&#41; seems to be a safe and effective method for severe hypertensive patients who are resistant to multiple drug treatment&#46; We present the case of a 52-year-old patient diagnosed with essential hypertension&#44; resistant to treatment with seven antihypertensive drugs&#46; After 10 hospitalisations without achieving adequate blood pressure control&#44; we decided to propose renal sympathetic denervation as an addition to medical treatment&#46; The procedure was performed without complications in the short to medium-long term&#44; achieving a significant improvement in blood pressure with the intention of reducing overall vascular risk&#46;</p>"
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