Salt-sensitive hypertension in chronic kidney disease: distal tubular mechanisms

Chronic kidney disease (CKD) causes salt-sensitive hypertension that is often resistant to treatment and contributes to the progression of kidney injury and cardiovascular disease. A better understanding of the mechanisms contributing to salt-sensitive hypertension in CKD is essential to improve these outcomes. This review critically explores these mechanisms by focusing on how CKD affects distal nephron Na⁺ reabsorption. CKD causes glomerulotubular imbalance with reduced proximal Na⁺ reabsorption and increased distal Na⁺ delivery and reabsorption. Aldosterone secretion further contributes to distal Na⁺ reabsorption in CKD and is not only mediated by renin and K⁺ but also by metabolic acidosis, endothelin-1, and vasopressin. CKD also activates the intrarenal renin-angiotensin system, generating intratubular angiotensin II to promote distal Na⁺ reabsorption. High dietary Na⁺ intake in CKD contributes to Na⁺ retention by aldosterone-independent activation of the mineralocorticoid receptor mediated through Rac1. High dietary Na⁺ also produces an inflammatory response mediated by T helper 17 cells and cytokines increasing distal Na⁺ transport. CKD is often accompanied by proteinuria, which contains plasmin capable of activating the epithelial Na⁺ channel. Thus, CKD causes both local and systemic changes that together promote distal nephron Na⁺ reabsorption and salt-sensitive hypertension. Future studies should address remaining knowledge gaps, including the relative contribution of each mechanism, the influence of sex, differences between stages and etiologies of CKD, and the clinical relevance of experimentally identified mechanisms. Several pathways offer opportunities for intervention, including with dietary Na⁺ reduction, distal diuretics, renin-angiotensin system inhibitors, mineralocorticoid receptor antagonists, and K⁺ or H⁺ binders.