Clinical features, diagnosis, and treatment of hypertensive nephrosclerosis
- Johannes FE Mann, MD
Johannes FE Mann, MD
- Professor of Medicine
- Friedrich Alexander University of Erlangen-Nürnberg
- International Scholar, Population Health Research Institute, McMaster University, Canada
- Karl F Hilgers, MD
Karl F Hilgers, MD
- Professor of Internal Medicine and Hypertension Research
- Friedrich-Alexander University, Erlangen-Nuremberg
- Vice Chair, Department of Nephrology and Hypertension
- Erlangen University Hospital
- Section Editors
- George L Bakris, MD
George L Bakris, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Professor of Medicine
- The University of Chicago
- Norman M Kaplan, MD
Norman M Kaplan, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Clinical Professor of Internal Medicine
- University of Texas Southwestern Medical Center
Hypertensive nephrosclerosis is a disorder that is usually associated with chronic hypertension. In addition to the level of blood pressure, it is clear that individual factors are involved. As an example, black patients have an approximate eight-fold elevation in the risk of hypertension-induced end-stage renal disease (ESRD) ; this increase in risk may persist even with "adequate" blood pressure control. Although low birth weight and bias in diagnosis based upon the patient's race may be involved, the recent recognition of an association between two independent sequence variants in the APOL1 gene on chromosome 22 and renal disease in African Americans, including focal segmental glomerular sclerosis and hypertension-related ESRD, provides a much more likely pathophysiologic mechanism  and suggests that hypertensive nephrosclerosis in blacks and whites may be distinct diseases. In addition, the histologic features of hypertensive nephrosclerosis may be observed in patients with normal blood pressure. (See "Epidemiology, classification, and pathogenesis of focal segmental glomerulosclerosis", section on 'FSGS in African Americans'.)
Hypertensive nephrosclerosis is characterized histologically by vascular, glomerular, and tubulointerstitial involvement (picture 1) . The histologic pattern of renal injury in patients with malignant hypertension (ie, malignant nephrosclerosis) is different, and is discussed separately. (See "Evaluation and treatment of hypertensive emergencies in adults" and "Moderate to severe hypertensive retinopathy and hypertensive encephalopathy in adults", section on 'Clinical manifestations and diagnosis'.)
Vascular disease — The vascular disease consists of intimal thickening and luminal narrowing of the large and small renal arteries and the glomerular arterioles. Two different processes appear to contribute to the development of the vascular lesions:
●A hypertrophic response to chronic hypertension that is manifested by medial hypertrophy and fibroblastic intimal thickening, leading to narrowing of the vascular lumen [4,5]. This response is initially adaptive by minimizing the degree to which the rise in systemic pressure is transmitted to the arterioles and capillaries .
●The deposition of hyaline-like material (plasma protein constituents, such as inactive C3b, part of the third component of complement) into the damaged, more permeable arteriolar wall .
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- Vascular disease
- Interstitial nephritis
- CLINICAL MANIFESTATIONS
- Incidence of renal failure
- Choice of antihypertensive agent
- - AASK trial
- Goal blood pressure
- Progression despite blood pressure control
- Improvement of renal function
- SUMMARY AND RECOMMENDATIONS