Hemodynamic theory of progressive renal disease: a 10-year update in brief review

Therapeutic progress. III: Diabetic nephropathy

Diabetic nephropathy is a common cause of end stage renal failure. Patients ultimately require dialysis or transplantation and endure a poor quality of life in association with increased mortality. Due to the quantitative significance of this problem there is also a considerable financial burden. It has been generally accepted that once nephropathy is established it is irreversible although aggressive anti-hypertensive treatment can delay its progression. More recently there have been numerous reports proposing a specific renal protective role of certain drugs. In this article we review the current literature on the use of angiotensin converting enzyme inhibitors in diabetic nephropathy. There is strong evidence that the use of ACE inhibitors in diabetic nephropathy (in the presence or absence of hypertension) slows the progression of deterioration in renal function and may even arrest its progression if detected at the microproteinuric stage.

Modulation of glomerular hypertension defines susceptibility to progressive glomerular injury

The fawn-hooded rat constitutes a spontaneous model for chronic renal failure with early systemic and glomerular hypertension, proteinuria (UpV) and high susceptibility to development of focal and segmental glomerular sclerosis (FGS). It has been argued that uninephrectomy (UNX) accelerates the development of glomerular injury by aggravation of glomerular hypertension and by an independent effect to promote glomerular enlargement. The present study was performed to further delineate the importance of these parameters for the development of FGS. At the age of eight weeks male rats were UNX and randomly assigned to either control (CON), enalapril (ENA) or Nw-nitro L-arginine methyl ester (NAME) treatment. In all groups glomerular hemodynamic studies were performed four weeks post-UNX. Systemic blood pressure and UpV were monitored for 4 to 12 weeks post-UNX. Kidneys were then prepared for morphologic study. ENA treatment achieved control of both systemic and glomerular hypertension, maintenance of glomerular hyperfiltration and hyperperfusion, increased ultrafiltration coefficient(Kf), and long-term protection against UpV and FGS. NAME rats showed aggravation of both systemic and glomerular hypertension, decreased renal perfusion and filtration with reduced Kf, and high filtration fraction. The incidence of FGS in NAME and CON groups was similar at 8 and 12 weeks post-UNX, respectively. Glomerular enlargement was present in CON and ENA rats, but did not correlate with injury, while glomerular tuft size was lowest in NAME rats, which displayed prominent glomerular injury. Systemic blood pressure correlated strongly with glomerular capillary pressure. We conclude that systemic and glomerular hypertension govern the development of UpV and FGS.(ABSTRACT TRUNCATED AT 250 WORDS)

Cellular biology of glomerulosclerosis

The burgeoning literature on glomerulosclerosis makes frequent review of the literature necessary. At this stage, the key processes involved have surely been defined. It is now appropriate to make deductions about possible therapies and to plan experiments and trials.

Hypertension-related renal injury: a major contributor to end-stage renal disease

The US Renal Data System Annual Report reveals that 57% of new cases and of end-stage renal disease are attributed to hypertensive nephropathy and diabetic nephropathy. Analyses of the data on serum creatinine from the Multiple Risk Factor Intervention Trial confirms that one in 20 of the hypertensive men exhibits a rate of decline in renal function that equals or exceeds 3% per year, the rate of loss being greater in older men, black men, and men with higher baseline blood pressure. Effective blood pressure treatment with maintenance of diastolic blood pressure below 95 mm Hg protected renal function in non-blacks but not in blacks, despite comparable blood pressure reduction in blacks. A longitudinal study of a diabetic cohort (n = 131) revealed that hypertension, plasma angiotensin II, and aldosterone are independent predictors of accelerated loss of renal function in diabetic nephropathy, possibly aggravated by diuretic usage as part of the antihypertensive regimen in diabetic nephropathy. No significant loss of renal function could be documented in those individuals whose blood pressure was adequately controlled (systolic blood pressure, < 140 mm Hg). These findings provide emphasis for the importance of adequate blood pressure control in both essential hypertension and hypertension associated with diabetes mellitus. They also provide support for the proposal that careful blood pressure control offers promise for reducing the incidence of end-stage renal disease in both hypertensive nephropathy and diabetic nephropathy.