Nephroprotection by antihypertensive therapy

Morbidity and mortality due to end-stage renal failure has become a major health concern in recent years and there is clear evidence that arterial hypertension constitutes a powerful risk factor for the progression of renal disease. Several studies have documented the benefit of blood pressure control on renal function, and it is increasingly recognized that antihypertensive therapy aimed at reducing blood pressure well below the target value of 140/90 mmHg further improves the overall renal survival rate. Different classes of antihypertensive agents show disparate specific nephroprotective properties that are unrelated to their blood pressure lowering properties. ACE inhibitors and calcium channel blockers have been reported to ameliorate renal function by favorably modifying renal and intraglomerular hemodynamics. In addition, both drugs exert beneficial effects on non-hemodynamic parameters of renal function. In contrast, beta-blockers and diuretics, although still being solely recommended as first line drugs in the management of arterial hypertension, can have adverse effects on renal function. Recently, long-term randomized controlled trials have consistently demonstrated the superior nephroprotective value of ACE inhibitors on renal function outcome. Whether AT1 receptor antagonists have similar effects on long-term renal survival is still under investigation. The outcome of forthcoming clinical trials is likely to influence clinical guidelines and optimize the medical regimen of human essential hypertension in patients with chronic renal insufficiency.