Hypertensive arteriolar nephrosclerosis is progressive renal impairment caused by chronic, poorly controlled hypertension. Symptoms and signs of chronic kidney disease may develop (eg, anorexia, nausea, vomiting, pruritus, somnolence or confusion), as may signs of end-organ damage secondary to hypertension. Diagnosis is primarily clinical, supported by ultrasonography and routine laboratory test findings. Treatment is strict blood pressure control and support of renal function.
Hypertensive arteriolar nephrosclerosis results when chronic hypertension damages small blood vessels, glomeruli, and tubulointerstitial tissues. As a result, progressive chronic kidney disease develops.
Hypertensive arteriolar nephrosclerosis progresses to end-stage renal disease in only a small percentage of patients. However, because chronic hypertension and hypertensive nephrosclerosis are common, hypertensive arteriolar nephrosclerosis is one of the most common diagnoses in patients with end-stage renal disease. It is often described as benign to distinguish it from malignant arteriolar nephrosclerosis, which is a synonym for hypertensive emergency.
Risk factors include
Older age
Poorly controlled moderate to severe hypertension
Other renal disorders (eg, diabetic nephropathy)
Black people are at increased risk; it is unclear if the risk is increased because poorly treated hypertension is more common among Black people or because they are more genetically susceptible to hypertension-induced renal damage.
Symptoms and Signs of Hypertensive Arteriolar Nephrosclerosis
Symptoms and signs of chronic kidney disease, such as anorexia, nausea, vomiting, pruritus, somnolence or confusion, weight loss, and an unpleasant taste in the mouth, may develop. Signs of hypertension-related end-organ damage may occur in the vasculature of the eyes and in the skin, central nervous system, and periphery.
Diagnosis of Hypertensive Arteriolar Nephrosclerosis
History of hypertension
Blood tests indicating renal failure
Signs of hypertensive end-organ damage
No other cause of chronic kidney disease
Urine testing should not suggest other causes of renal failure (eg, glomerulonephritis, hypertensive emergency). On urinalysis, there should be few cells or casts in the sediment, and protein excretion is usually < 1 g/day (it is occasionally higher and in the nephrotic range).
Image provided by Agnes Fogo, MD, and the American Journal of Kidney Diseases' Atlas of Renal Pathology (see www.ajkd.org).
Ultrasonography should be done to exclude other causes of renal failure. It may show that kidney size is reduced. Renal biopsy is done only if the diagnosis remains unclear.
Treatment of Hypertensive Arteriolar Nephrosclerosis
Blood pressure (BP) control
Treatment involves strict BP control. The current recommendation of BP goal is 120 to 130/< 80 mm Hg for most patients (1Chronic kidney disease should be managed.
Treatment reference
1. Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group: KDIGO 2021 clinical practice guideline for the management of blood pressure in chronic kidney disease. Kidney Int 99(3S):S1-S87, 2021. doi: 10.1016/j.kint.2020.11.003
Prognosis for Hypertensive Arteriolar Nephrosclerosis
Prognosis usually depends on adequacy of blood pressure control and degree of renal failure. Usually, renal impairment progresses slowly; after 5 to 10 years, only 1 to 2% of patients develop clinically significant renal dysfunction.
Key Points
Chronic hypertension can cause hypertensive arteriolar nephrosclerosis, resulting in chronic kidney disease and, infrequently, end-stage renal disease.
Suspect the diagnosis if chronic hypertension precedes onset of renal insufficiency.
Do ultrasonography to check for other causes of renal failure.
Treat most patients with an ACE inhibitor or ARB, and possibly other medications, to control BP.
