Hypertensive nephrosclerosis pathogenesis, diagnosis and management.

Nephrovasculopathies are an increasing cause of end-stage renal failure. Hypertensive nephroscierosis is an old concept. In fact, the renal vascular lesions corresponding to this term can result from aging or a host of parenchymal renal diseases in the absence of elevated blood pressure. Nephrosclerosis is overdiagnosed. The diagnosis should rest only on renal biopsy, which is not usually done in an elderly patient with chronic renal insufficiency, hypertension and atrophic kidneys. Atherosclerotic renal disease and renal cholesterol crystal embolism are often misdiagnosed for nephro-sclerosis. The classical picture of nephrosclerosis is the patient with primary hypertension accompanied by arterio-and arteriolonephrosclerosis, focal and segmental glomerulo-sclerosis leading to glomerular obsolescence, interstitial fibrosis and inflammatory infiltrates. However, similar lesions can be observed in animal models as well as in some humans, especially blacks, in the absence of, or preceding the onset of hypertension. This suggests that nephrosclerosis might stem from a genetic defect in the renal vascular bed, a defect closely associated with the hypertensive trait. Recent data regarding the link between low birthweight and hypertension of early onset might have bearing on future developments in understanding the pathogenesis of nephrosclerosis. Treatment pursues two goals: normalizing blood pressure according to international recommendations and retarding sclerosis with a regimen essentially based on angiotensin II antagonists.