Effect of antihypertensive treatment on renal function in primary (essential) hypertension
- Johannes FE Mann, MD
Johannes FE Mann, MD
- Professor of Medicine
- Friedrich Alexander University of Erlangen
- Karl F Hilgers, MD
Karl F Hilgers, MD
- Professor of Medicine and Hypertension Research
- University of Erlangen-Nuremberg
- Section Editors
- George L Bakris, MD
George L Bakris, MD
- Section Editor — Hypertension
- Professor of Medicine
- The University of Chicago
- Norman M Kaplan, MD
Norman M Kaplan, MD
- Section Editor — Hypertension
- Clinical Professor of Internal Medicine
- University of Texas Southwestern Medical Center
Renal function may deteriorate because of uncontrolled hypertension. Even minimal elevations in blood pressure (BP), still below the 140/90 mmHg level used to define hypertension, are associated with increased renal arteriosclerosis in autopsies . Since adequate control of hypertension may slow the rate of renal dysfunction , the effects of antihypertensive therapy on renal function need to be carefully considered.
Antihypertensive therapy has both acute and chronic effects on renal function in patients with primary hypertension (formerly called "essential" hypertension). In early disease, for example, renal function is usually normal; in this setting, lowering the BP induces little change in glomerular filtration rate (GFR) . In comparison, some patients have early renal vasoconstriction leading to a fall in GFR below 80 mL/min. Reversal of the vasoconstriction with an angiotensin-converting enzyme (ACE) inhibitor or calcium channel blocker can raise the GFR by 20 to 30 mL/min in these patients . (See "Renal effects of ACE inhibitors in hypertension".) Blacks may have an initial decrease in GFR compared with an increase in whites .
This topic reviews the chronic and acute effects of antihypertensive therapy in patients with primary hypertension. Goal blood pressure and the choice of antihypertensive agent are discussed in separate topics. (See "What is goal blood pressure in the treatment of hypertension?" and "Antihypertensive therapy and progression of nondiabetic chronic kidney disease in adults" and "Treatment of hypertension in patients with diabetes mellitus".)
Patients with prolonged uncontrolled hypertension are at increased risk of developing chronic renal failure . The risk of this complication is much greater in blacks and in patients with moderate and severe hypertension (figure 1). (See "Hypertensive complications in blacks".)
It must be emphasized, however, that the percentage of patients with mild hypertension who develop end-stage renal disease (ESRD) is relatively small, being less than 1 percent after 16 years in the MRFIT trial . (See "Clinical features, diagnosis, and treatment of hypertensive nephrosclerosis", section on 'Incidence of renal failure'.)
- Ninomiya T, Kubo M, Doi Y, et al. Prehypertension increases the risk for renal arteriosclerosis in autopsies: the Hisayama Study. J Am Soc Nephrol 2007; 18:2135.
- Jafar TH, Stark PC, Schmid CH, et al. Progression of chronic kidney disease: the role of blood pressure control, proteinuria, and angiotensin-converting enzyme inhibition: a patient-level meta-analysis. Ann Intern Med 2003; 139:244.
- Hall WD, Kusek JW, Kirk KA, et al. Short-term effects of blood pressure control and antihypertensive drug regimen on glomerular filtration rate: the African-American Study of Kidney Disease and Hypertension Pilot Study. Am J Kidney Dis 1997; 29:720.
- Morrone LF, Ramunni A, Fassianos E, et al. Nitrendipine and amlodipine mimic the acute effects of enalapril on renal haemodynamics and reduce glomerular hyperfiltration in patients with chronic kidney disease. J Hum Hypertens 2003; 17:487.
- Mitchell HC, Smith RD, Cutler RE, et al. Racial differences in the renal response to blood pressure lowering during chronic angiotensin-converting enzyme inhibition: a prospective double-blind randomized comparison of fosinopril and lisinopril in older hypertensive patients with chronic renal insufficiency. Am J Kidney Dis 1997; 29:897.
- Klag MJ, Whelton PK, Randall BL, et al. Blood pressure and end-stage renal disease in men. N Engl J Med 1996; 334:13.
- Messerli FH, Frohlich ED, Dreslinski GR, et al. Serum uric acid in essential hypertension: an indicator of renal vascular involvement. Ann Intern Med 1980; 93:817.
- Reynolds T. Serum uric acid, the endothelium and hypertension: an association revisited. J Hum Hypertens 2007; 21:591.
- Lazarus JM, Bourgoignie JJ, Buckalew VM, et al. Achievement and safety of a low blood pressure goal in chronic renal disease. The Modification of Diet in Renal Disease Study Group. Hypertension 1997; 29:641.
- Perneger TV, Nieto FJ, Whelton PK, et al. A prospective study of blood pressure and serum creatinine. Results from the 'Clue' Study and the ARIC Study. JAMA 1993; 269:488.
- Coresh J, Wei GL, McQuillan G, et al. Prevalence of high blood pressure and elevated serum creatinine level in the United States: findings from the third National Health and Nutrition Examination Survey (1988-1994). Arch Intern Med 2001; 161:1207.
- Maki DD, Ma JZ, Louis TA, Kasiske BL. Long-term effects of antihypertensive agents on proteinuria and renal function. Arch Intern Med 1995; 155:1073.
- Mulrow CD, Townsend RR. Guiding lights for antihypertensive treatment in patients with nondiabetic chronic renal disease: proteinuria and blood pressure levels? Ann Intern Med 2003; 139:296.
- Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 39. UK Prospective Diabetes Study Group. BMJ 1998; 317:713.
- Lo SH, Mo KL, Wong KS, et al. Aristolochic acid nephropathy complicating a patient with focal segmental glomerulosclerosis. Nephrol Dial Transplant 2004; 19:1913.
- Weiner DE, Tighiouart H, Levey AS, et al. Lowest systolic blood pressure is associated with stroke in stages 3 to 4 chronic kidney disease. J Am Soc Nephrol 2007; 18:960.
- Hricik DE. Captopril-induced renal insufficiency and the role of sodium balance. Ann Intern Med 1985; 103:222.
- Bakris GL, Weir MR. Angiotensin-converting enzyme inhibitor-associated elevations in serum creatinine: is this a cause for concern? Arch Intern Med 2000; 160:685.
- Hirsch S, Hirsch J, Bhatt U, Rovin BH. Tolerating increases in the serum creatinine following aggressive treatment of chronic kidney disease, hypertension and proteinuria: pre-renal success. Am J Nephrol 2012; 36:430.
- Ruggenenti P, Remuzzi G. Dealing with renin-angiotensin inhibitors, don't mind serum creatinine. Am J Nephrol 2012; 36:427.