Abstract
BACKGROUND: Renal denervation (RDN) is an emerging therapy for resistant hypertension. However, use of iodinated contrast during the procedure raises concern for contrast-induced kidney injury in patients with chronic kidney disease (CKD). Carbon dioxide (CO(2)) angiography may provide a safer alternative. CASE SUMMARY: An 85-year-old man with stage 3a CKD and refractory hypertension despite 5 medications underwent ultrasound-guided RDN (uRDN). After minimal iodinated contrast for access confirmation, CO(2) angiography was used to visualize the bilateral renal arteries and guide ablation. Three ablations were delivered to each artery, and the procedure was uneventful. At 5-week follow-up, serum creatinine improved (1.3 mg/dL), and antihypertensive therapy was reduced from 5 to 3 agents. DISCUSSION: CO(2) angiography allows safe renal artery visualization without nephrotoxic exposure, making it particularly valuable in CKD patients where contrast-induced injury is a concern. TAKE-HOME MESSAGE: CO(2)-guided uRDN is a safe, non-nephrotoxic option for refractory hypertension in patients with CKD.