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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Chronic systemic hypertension before the onset of proteinuria

  • Declining renal function; proteinuria; anemia

  • Renal biopsy evidence of arteriolonephrosclerosis, glomerulosclerosis, tubular atrophy, interstitial fibrosis, and inflammatory infiltrates

GENERAL CONSIDERATIONS

  • The cause of hypertensive nephrosclerosis is still unknown and is not always prevented by the treatment of hypertension

  • Thus, there is debate about optimal blood pressure levels to prevent this complication

  • Hypertensive nephrosclerosis is one of the most common causes of end-stage renal disease

  • Once initiated, the condition is progressive

  • It is more common in males of African origin

  • Once renal disease ensues, it can cause hypertension

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Typically nonspecific symptoms of hypertension

PHYSICAL EXAM FINDINGS

  • Elevated blood pressure without a nocturnal dip

  • Retinopathy may be seen

  • Left ventricular lift or heave

DIFFERENTIAL DIAGNOSIS

  • Unless renal biopsy is performed, hypertensive nephrosclerosis is a diagnosis of exclusion

  • Parenchymal renal disease

  • Renovascular hypertension with renal insufficiency

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Urinalysis: hyaline and granular casts, microalbuminuria

  • Elevated serum creatinine, uric acid

  • Anemia

ELECTROCARDIOGRAPHY

  • Left ventricular and atrial hypertrophy

IMAGING STUDIES

  • Renal ultrasound may show small kidneys with cortical thinning

DIAGNOSTIC PROCEDURES

  • Renal biopsy is diagnostic

TREATMENT

CARDIOLOGY REFERRAL

  • Hypertension that is difficult to control

  • Suspected cardiac disease

HOSPITALIZATION CRITERIA

  • Renal failure

MEDICATIONS

  • Twenty-four-hour blood pressure < 130/85 mm Hg with multiple drugs as necessary

  • Sodium restriction and diuretics

  • Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are best first therapy

THERAPEUTIC PROCEDURES

  • Renal dialysis if necessary

MONITORING

  • ECG and blood pressure in hospital

ONGOING MANAGEMENT

FOLLOW-UP

  • Depends on blood pressure control

COMPLICATIONS

  • End-stage renal disease

PROGNOSIS

  • Renal dialysis rate is 5–10% per year

  • Survival is 85% at 5 years and 50% at 10 years

  • The most common cause of death is cardiovascular disease

PREVENTION

  • Adequate blood pressure control; optimal blood pressure levels have not been determined, but < 135/85 mm Hg is recommended

RESOURCES

PRACTICE GUIDELINES

  • Although ACE inhibitors or ARBs are considered the preferred treatment, monotherapy rarely controls the blood pressure adequately

  • The choice of other agents depends on the volume status of the patient. If there is edema, loop diuretics should be added, then other agents

REFERENCES

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