The diagnostic dilemma of hypertensive nephrosclerosis: the nephrologist's view

The appearance of progressive renal disease in elderly patients with essential hypertension, sometimes irrespective of blood pressure control, is frequently related to the association of hypertension and atheromatous renal disease. This disease may lead to renal failure through a renal artery stenosis and/or chronic microembolization into the kidney. Nonsevere uncomplicated essential hypertension is constantly associated with renal vascular changes that are qualitatively indistinguishable from those related to aging. Notwithstanding the fairly constant presence of so-called benign hypertensive nephrosclerosis in patients with established hypertension, only a subset of these patients show progressive renal damage. Three mechanisms of progression may be at play: (1) a combination of ischemic and hypertensive glomerular mechanisms in some susceptible humans; (2) nonhemodynamic factors such as local immune mechanisms; or (3) the involvement of metabolic abnormalities which favor glomerulosclerosis.