Pathophysiology of progressive renal failure.

Progressive renal failure is conditioned by a number of factors, including type of renal disease, sex, level of arterial pressure, insulin deficiency and/or hyperglycemia in diabetes mellitus, and dietary protein intake. Elevated arterial pressure may cause a progressive renal disease, hypertensive nephrosclerosis, and accelerate the rate of progression of all other chronic renal disease. Hypertension contributes to progressive renal failure by inducing myointimal hyperplasia of arcuate and afferent arterioles, causing glomerular ischemia, and by increasing pressure in the glomerular capillaries. The latter leads to hyperfiltration of protein, increased mesangial ingestion of protein, and glomerular sclerosis. Increased glomerular pressure may also be induced by protein feeding, insulin deficiency and hyperglycemia, especially in the presence of reduced nephron number. Thus at least one common mechanism underlies the effect of hypertension, protein feeding, and diabetes on the progression of chronic renal disease.