Antihypertensive therapy and the progression of renal disease

Systemic hypertension accelerates the progression of glomerular injury. Studies in experimental animals indicate that the beneficial effects of antihypertensive agents may relate to their intrarenal haemodynamic consequences, and specifically to their effects on the arteriolar resistances. Relative afferent arteriolar vasodilation allows transmission of systemic pressure into the glomerular capillary network; the resultant glomerular capillary hypertension is associated with progressive structural injury. Antihypertensive agents, such as angiotensin converting enzyme (ACE) inhibitors, relax the efferent arteriole, alleviate glomerular hypertension and protect the kidney from progressive injury. These agents are effective in numerous animal models, and preliminary clinical observations suggest that they may also be effective in humans. In contrast, vasodilator/diuretic regimens are effective in some animal models, but fail to reduce glomerular pressure or injury in others. Less is known about the potential renal protective effects of calcium channel blockers, with reported observations offering conflicting findings. Further experimental and clinical studies are needed to define the optimal antihypertensive therapy for patients at risk of glomerular injury.