Hypertension as cause of end-stage renal disease: lessons from international registries

The incidence of hypertension as cause of ESRD has doubled in the ERA-EDTA Registry in the past two decades, going from 7 to 13%. It is very possible that this is not a real increase in the incidence of hypertension as cause of ESRD, but rather a consequence of greater acceptance of older patients, a phenomenon that has simultaneously occurred. There are geographic differences in the incidence of hypertension as cause of ESRD, from 6% in Japan to 28.5% in the U.S., and 13% in Europe. With the present data, it is impossible to know if these differences are real. The diagnostic criteria used are not uniform and a consensus would be necessary to establish uniform diagnostic criteria for nephrosclerosis or ischemic nephropathy. The percentage of patients starting renal replacement therapy (RRT) with unknown primary renal disease is very different in the U.S. and Europe. This could be a critical factor in explaining these differences. Survival of patients at 5 and 10 years with renal vascular disease did not improve from 1977 to 1989. The same occurs with survival of patients with standard primary renal disease, although this is better than that of patients with renal vascular disease. To interpret this lack of improvement in survival of patients over a decade, we must take into account that at the same time there has been a significant increase in the age of patients starting RRT. Therefore, when the population of patients of under 55 is analyzed, there is evidence that those starting treatment in the 80's have much better survival than those starting in the 70's. However, survival of patients with renal vascular disease continues to be poorer than that of patients with standard primary renal disease. This lower survival of patients with renal vascular disease seems to be related to higher cardiac mortality, which is in alignment with the diagnosis of hypertension as cause of renal failure.