Hypertensive arteriolar nephrosclerosis results when chronic hypertension damages small blood vessels, glomeruli, renal tubules, and interstitial tissues. As a result, progressive chronic kidney disease develops.
Hypertensive arteriolar nephrosclerosis progresses to end-stage renal disease in only a small percentage of patients. However, because chronic hypertension and hypertensive nephrosclerosis are common, hypertensive arteriolar nephrosclerosis is one of the most common diagnoses in patients with end-stage renal disease. It is often described as benign to distinguish it from malignant arteriolar nephrosclerosis, which is a synonym for hypertensive emergency.
Risk factors include
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Older age
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Poorly controlled moderate to severe hypertension
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Other renal disorders (eg, diabetic nephropathy)
Blacks are at increased risk; it is unclear if the risk is increased because poorly treated hypertension is more common among blacks or because blacks are more genetically susceptible to hypertension-induced renal damage.
Symptoms and Signs
Symptoms and signs of chronic kidney disease, such as anorexia, nausea, vomiting, pruritus, somnolence or confusion, weight loss, and an unpleasant taste in the mouth, may develop. Signs of hypertension-related end-organ damage may occur in the vasculature of the eyes and in the skin, central nervous system, and periphery.
Diagnosis
The diagnosis may be suspected when routine blood tests indicate deteriorating renal function (eg, elevated creatinine and blood urea nitrogen, hyperphosphatemia) in a hypertensive patient. Diagnosis is usually inferred because of the history and evidence of hypertension-related end-organ damage (eg, retinal changes, left ventricular hypertrophy) on physical examination. Hypertension should be present before onset of proteinuria and renal failure, and there should be no other clinically suspected cause of renal failure.
Urine testing should not suggest other causes of renal failure (eg, glomerulonephritis, hypertensive emergency). On urinalysis, there should be few cells or casts in the sediment, and protein excretion is usually < 1 g/day (it is occasionally higher and in the nephrotic range).
Ultrasonography should be done to exclude other causes of renal failure. It may show that kidney size is reduced. Renal biopsy is done only if the diagnosis remains unclear.
Prognosis
Treatment
Treatment involves strict BP control. The BP goal is < 130 to 140/80 to 90 mm Hg. Most experts suggest using an angiotensin II receptor blocker (ARB) or an angiotensin-converting enzyme (ACE) inhibitor for patients who have proteinuria. Calcium channel blockers and thiazide diuretics can be used as first-line drugs; most patients require combination therapy for BP control. Weight loss, exercise, and salt and water restriction also help control BP. Chronic kidney disease should be managed.
Key Points
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Chronic hypertension can cause hypertensive arteriolar nephrosclerosis, resulting in chronic kidney disease and, infrequently, end-stage renal disease.
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Suspect the diagnosis if chronic hypertension precedes onset of renal insufficiency.
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Do ultrasonography to check for other causes of renal failure.
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Treat most patients with an ACE inhibitor or ARB and possibly other drugs.
