Hypertensive Nephrosclerosis

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