Hypertensive kidney disease: a true epidemic or rare disease?

In the industrialized world, hypertension affects approximately 30% of the general population. Hypertensive kidney disease is considered one of the consequences of long-term and poorly controlled hypertension. According to renal databases, it is a leading cause of end‑stage renal failure, second only to diabetic kidney disease. We challenge this dogma by emphasizing lack of specificity of both clinical and morphological presentations of hypertension‑related kidney disease and very low prevalence of hypertensive kidney disease that is diagnosed based on kidney biopsy findings in registries. In most cases of concomitant hypertension and chronic kidney disease (CKD), the sequence of events (ie, which came first, CKD or hypertension) cannot be established. Arterial hypertension plays a role in the pathogenesis of chronic vascular disease and may occasionally lead to arterionephrosclerosis, but its general significance in the evolution of CKD and prevalence among CKD patients appear to be highly overestimated. Studies of the morphology of kidney biopsies have indicated that arterionephrosclerosis, classically considered a morphological equivalent of the clinical term "hypertensive kidney disease"(previously referred to as "hypertensive nephropathy"), most commonly superimposes upon variable chronic renal diseases, even in the absence of elevated blood pressure. To date, no prospective controlled clinical trials have been conducted in primary hypertension patients with renal events as primary endpoints. Data from available clinical trials with renal events that serve as secondary endpoints suggest that lowering blood pressure below current targets may provide additional cardiovascular benefits but may be harmful to the kidneys.