Renal denervation in 2026: trial evidence, guideline recommendations and implementation strategies for clinical practice

Renal nerves are critical modulators of kidney function and blood pressure (BP) control. Their influence on sodium and fluid retention, renin release and vasoconstriction rendered them a therapeutic target more than a century ago when surgical splanchnicectomy emerged as one of the first effective antihypertensive therapies. Revisiting the concept using catheter-based approaches to ablate renal afferent and efferent nerves more selectively with various energy sources demonstrated the efficacy of renal denervation in reducing sympathetic nerve activity. A series of sham-controlled randomised clinical trials in patients with uncontrolled or resistant hypertension either on or off concomitant antihypertensive drugs demonstrated procedural safety and clinically meaningful BP reduction. Durability of the BP lowering efficacy has been demonstrated out to 10 years in observational studies. Major international guidelines now recommend renal denervation as an adjunct therapy in patients with uncontrolled or resistant hypertension where other means have failed or resulted in insufficient BP control. Patient selection and patient preference are relevant aspects to be considered in a shared decision-making process leading up to the denervation procedure, which should be performed in experienced centres. While approved in the USA, most countries in Europe, Asia-Pacific and many other regions lack adequate reimbursement currently, which remains a barrier for more widespread implementation into clinical practice despite favourable cost-effectiveness analyses. While now established in the context of hypertension management, ongoing research explores its potential utility in other conditions characterised by increased sympathetic drive, with most promising results in patients with chronic kidney disease, atrial fibrillation, heart failure and others. Further refinement of procedural aspects may reduce procedure time and augment the BP lowering efficacy. Clinicians should embrace the additional options that device-based therapies offer to improve BP management, mostly in combination with pharmacologic therapies. After all, it is just another means of bringing the pressure down.