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Determinants of Hypertensive Renal Disease and Its Progression

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Disorders of Blood Pressure Regulation

Part of the book series: Updates in Hypertension and Cardiovascular Protection ((UHCP))

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Abstract

The susceptibility to hypertension-induced renal damage (HIRD) varies greatly within the hypertensive population. With the exception of certain genetically susceptible groups such as African-Americans, the vast majority of individuals with essential hypertension (HTN) are quite resistant to the development of significant HIRD. This is because the normal preglomerular renal autoregulatory mechanisms prevent the transmission of systemic HTN to glomerular capillaries protecting them from barotrauma. Significant HIRD only develops when HTN becomes very severe and exceeds this protective capacity. By contrast, these protective autoregulatory mechanisms are impaired in individuals with significant CKD including those with diabetic nephropathy. This impairment allows an enhanced glomerular transmission of even moderate HTN and results in progressive glomerular barotrauma and glomerulosclerosis (GS). Studies in renal mass reduction (RMR) models of CKD have confirmed the quantitative importance of autoregulatory impairment and physical glomerular BP transmission as the predominant determinant of HIRD severity and its rate of progression. Recent data indicate that the loss of NO-mediated efferent vasodilation may independently contribute to the pathogenesis of HIRD in states of endothelial dysfunction. The CKD-associated glomerular capillary hypertrophy may additionally increase HIRD susceptibility due to a reduction in podocyte density and the ability to withstand mechanical stress. Although the renin-angiotensin system (RAS) is widely believed to promote HIRD through BP-independent fibrogenic pathways, most of the benefits of RAS blockade are attributable to BP lowering when BP has been measured adequately. Nevertheless, RAS blockade combined with adequate diuretic therapy offers the most effective strategy to control BP and thereby CKD progression.

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Authors and Affiliations

  1. Edward Hines Jr. VA Hospital, Hines, IL, 60141, USA

    Karen A. Griffin, Aaron J Polichnowski & Anil K. Bidani

  2. Loyola University Medical Center, 2160 South First Avenue, Maywood, IL, 60153, USA

    Karen A. Griffin, Aaron J Polichnowski & Anil K. Bidani

Authors
  1. Karen A. Griffin
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  2. Aaron J Polichnowski
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Correspondence to Karen A. Griffin .

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Editors and Affiliations

  1. Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon

    Adel E. Berbari

  2. Emeritus Professor of Medicine, University of Milano-Bicocca, Monza, Italy

    Giuseppe Mancia

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Griffin, K.A., Polichnowski, A.J., Bidani, A.K. (2018). Determinants of Hypertensive Renal Disease and Its Progression. In: Berbari, A., Mancia, G. (eds) Disorders of Blood Pressure Regulation. Updates in Hypertension and Cardiovascular Protection. Springer, Cham. https://doi.org/10.1007/978-3-319-59918-2_27

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  • DOI: https://doi.org/10.1007/978-3-319-59918-2_27

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