Updated: 2/28/2019

Hypertensive Nephrosclerosis

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Snapshot
  • A 42-year-old African American woman presents to her physician’s office for an annual visit. She has a long-standing history of hypertension and is currently not on any medication. On routine laboratory examination, she is found to have a creatinine of 1.5 mg/dL. Urine studies reveal mild proteinuria. Her physician prescribes lisinopril for her hypertension and likely renal disease.
Introduction
  • Clinical definition
    • this represents renal sclerosis
      • nephrosclerosis is associated with chronic hypertension
        • this is distinct from malignant hypertension or malignant nephrosclerosis
  • Epidemiology
    • demographics
      • common in people of African descent
    • risk factors
      • hypertension
      • chronic renal disease
  • Pathogenesis
    • involves the vasculature, glomeruli, tubules, and interstitium of the kidney
      • chronic hypertension causes medial and intimal hypertrophy
        • this causes narrowed vessels and ischemia
          • ischemic damage to kidneys also can cause glomerulosclerosis
            • vessel walls are further damaged by hyaline-like material deposition
      • interstitial nephritis is often found on biopsy and the exact mechanism is unknown
Presentation
  • Symptoms
    • hypertension precedes proteinuria or renal insufficiency
  • Physical exam
    • typically benign
Studies
  • Labs 
    • ↑ creatinine
    • ↑ blood urea nitrogen
    • ↑ uric acid
  • Urinalysis
    • few casts
    • typically benign
    • mild proteinuria (< 1 g/day)
  •  Gross specimen
    • cobblestone appearance
  • Diagnostic criteria
    • hypertension precedes proteinuria or renal insufficiency
    • no other causes of renal disease
    • biopsy is not necessary
Differential
  • Malignant nephrosclerosis
Treatment
  • Medical
    • angiotensin converting enzyme (ACE) inhibitors
      • indications
        • for all patients with hypertension-associated nephrosclerosis
    • angiotensin II receptor blockers
      • indications
        • if ACE inhibitors are contraindicated
Complications
  • Renal failure
    • typically only occurs in patients with concomitant other renal disease

 

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