Hypertensive renal disease: a growing cause of renal failure

Kidney disease and hypertension: Hypertension is increasingly associated to renal insufficiency leading to end stage renal damage (ESRD), through several mechanisms involving renal vasculature. Ten to 25% of new ESRD patients are now categorized as hypertensive nephropathy and vascular renal disease. Epidemiology in France: Besides the risk of spontaneously evolving atheromatous stenoses of renal arteries, the individual risk of ESRD in essential hypertension is relatively low, except in selected genetic backgrounds such as black people especially in the USA. In long term studies, the risk of ESRD in treated hypertensives is between 1.5 and 3% at 15 years, and approximately 3% of French hypertensives have plasma creatinine levels above 150 mu mol/l. The risk of significant creatinine increase is doubled each 20 mmHg increment in diastolic BP, but long term studies suggest that the influence of systolic BP is even greater. Perspectives: Animal models have extended our pathophysiological view of hypertensive nephropathy, in which renal ischemia and nephron loss will induce preglomerular vasodilation and glomerular hypertension. In the future, the evaluation of the renal prognosis in essential hypertension could benefit from indirect renal hemodynamic explorations, genetic progress, determination of microalbuminuria which is the renal probe of a more generalized microvascular disease, these indices should be useful to adapt the antihypertensive therapy, with the goal of normalizing blood pressure at a lowest albumin excretion rate.