Some concerns of this methodology specifically for CKD patients have to considered. First, in patients with low GFR renal blood flow can be particularly reduced. Since cooling of the catheter tip depends decisively on the blood flow, thermal problems might occur increasing the potential for damage of the renal blood vessels. Second, the procedure requires substantial amounts of contrast media raising the risk of acute kidney injury in these patients. Of interest, Hering et al. observed no deterioration in renal function over the course of the study in CKD patients.

The Simplicity Study III, a randomized controlled study, failed to demonstrate a beneficial effect of renal denervation on BP in a large group of patients with resistant hypertension [54]. Given these unimpressive results, the role of renal denervation in the management of resistant hypertension, particularly in CKD patients, remains to be established. Several issues need to be resolved: first, how to identify patients with increased renal sympathetic nerve activity , who may be more suitable for renal denervation; second, to what extent and with what variability renal denervation is achieved with the Simplicity catheter by various investigators; third, the issue of regeneration of renal nerves after denervation remains unresolved. Until all these issues are satisfactorily resolved, renal denervation should remain an experimental tool in the management of hypertension associated with kidney disease .