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Sympathetic activation contributes to the progression of CKD and is associated with adverse cardiovascular outcomes. Ablation of renal sympathetic nerves reduces sympathetic nerve activity and BP in patients with resistant hypertension and preserved renal function, but whether this approach is safe and effective in patients with an estimated GFR (eGFR)< 45 ml/min per 1.73 m 2 is unknown. We performed bilateral renal denervation in 15 patients with resistant hypertension and stage 3–4 CKD (mean eGFR, 31 ml/min per 1.73 m 2). We used CO 2 angiography in six patients to minimize exposure to contrast agents. Estimated GFR remained unchanged after the procedure, irrespective of the use of CO 2 angiography. Mean baseline BP±SD was 174±22/91±16 mmHg despite the use of 5.6±1.3 antihypertensive drugs. Mean changes in office systolic and diastolic BP at 1, 3, 6, and 12 months were− 34/− 14,− 25/− 11 …