Renal Endowment: Developmental Origins of Adult Disease

Blood Lead Levels in U.S. Women of Childbearing Age, 1976-2016

BACKGROUND

Lead can adversely affect maternal and child health across a wide range of exposures; developing fetuses and breastfeeding infants may be particularly vulnerable. We describe the distribution of blood lead levels (BLLs) in U.S. women of childbearing age and associations with sociodemographic, reproductive, smoking, and housing characteristics over a 40-y period.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES) II, NHANES III Phase I and Phase II, and 1999-2016 continuous NHANES were used to describe the distribution of BLLs (given in micrograms per deciliter; 1μg/dL=0.0483μmol/L) in U.S. women 15-49 years of age between 1976 and 2016. For all women with valid BLLs (n=22,408), geometric mean (GM) BLLs and estimated prevalence of BLLs ≥5μg/dL were calculated overall and by selected demographic characteristics. For NHANES II, estimated prevalence of BLLs ≥10 and ≥20μg/dL were also calculated.

RESULTS

The most recent GM BLLs (2007-2010 and 2011-2016, respectively) were 0.81μg/dL [95% confidence interval (CI): 0.79, 0.84] and 0.61μg/dL (95% CI: 0.59, 0.64). In comparison, GM BLLs in earlier periods (1976-1980, 1988-1991, and 1991-1994) were 10.37μg/dL (95% CI: 9.95, 10.79), 1.85μg/dL (95% CI: 1.75, 1.94), and 1.53μg/dL (95% CI: 1.45, 1.60), respectively. In 2011-2016, 0.7% of women of childbearing age had BLLs ≥5μg/dL, and higher BLLs were associated with older age, other race/ethnicity, birthplace outside the United States, four or more live births, exposure to secondhand tobacco smoke, and ever pregnant or not currently pregnant.

DISCUSSION

Lead exposure in U.S. women of childbearing age is generally low and has substantially decreased over this 40-y period. However, based on these estimates, there are still at least 500,000 U.S. women being exposed to lead at levels that may harm developing fetuses or breastfeeding infants. Identifying high-risk women who are or intend to become pregnant remains an important public health issue. https://doi.org/10.1289/EHP5925.

Blood Lead Levels in U.S. Women of Childbearing Age, 1976-2016

BACKGROUND

Lead can adversely affect maternal and child health across a wide range of exposures; developing fetuses and breastfeeding infants may be particularly vulnerable. We describe the distribution of blood lead levels (BLLs) in U.S. women of childbearing age and associations with sociodemographic, reproductive, smoking, and housing characteristics over a 40-y period.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES) II, NHANES III Phase I and Phase II, and 1999-2016 continuous NHANES were used to describe the distribution of BLLs (given in micrograms per deciliter; 1μg/dL=0.0483μmol/L) in U.S. women 15-49 years of age between 1976 and 2016. For all women with valid BLLs (n=22,408), geometric mean (GM) BLLs and estimated prevalence of BLLs ≥5μg/dL were calculated overall and by selected demographic characteristics. For NHANES II, estimated prevalence of BLLs ≥10 and ≥20μg/dL were also calculated.

RESULTS

The most recent GM BLLs (2007-2010 and 2011-2016, respectively) were 0.81μg/dL [95% confidence interval (CI): 0.79, 0.84] and 0.61μg/dL (95% CI: 0.59, 0.64). In comparison, GM BLLs in earlier periods (1976-1980, 1988-1991, and 1991-1994) were 10.37μg/dL (95% CI: 9.95, 10.79), 1.85μg/dL (95% CI: 1.75, 1.94), and 1.53μg/dL (95% CI: 1.45, 1.60), respectively. In 2011-2016, 0.7% of women of childbearing age had BLLs ≥5μg/dL, and higher BLLs were associated with older age, other race/ethnicity, birthplace outside the United States, four or more live births, exposure to secondhand tobacco smoke, and ever pregnant or not currently pregnant.

DISCUSSION

Lead exposure in U.S. women of childbearing age is generally low and has substantially decreased over this 40-y period. However, based on these estimates, there are still at least 500,000 U.S. women being exposed to lead at levels that may harm developing fetuses or breastfeeding infants. Identifying high-risk women who are or intend to become pregnant remains an important public health issue. https://doi.org/10.1289/EHP5925.

Restricted nutrition-induced low birth weight, low number of nephrons and glomerular mesangium injury in Japanese quail

Insufficient nutrition during the perinatal period causes structural alterations in humans and experimental animals, leading to increased vulnerability to diseases in later life. Japanese quail, Coturnix japonica, in which partial (8-10%) egg white was withdrawn (EwW) from eggs before incubation had lower birth weights than controls (CTs). EwW birds also had reduced hatching rates, smaller glomeruli and lower embryo weight. In EwW embryos, the surface condensate area containing mesenchymal cells was larger, suggesting that delayed but active nephrogenesis takes place. In mature EwW quail, the number of glomeruli in the cortical region (mm2) was significantly lower (CT 34.7±1.4, EwW 21.0±1.2); capillary loops showed focal ballooning, and mesangial areas were distinctly expanded. Immunoreactive cell junction proteins, N-cadherin and podocin, and slit diaphragms were clearly seen. With aging, the mesangial area and glomerular size continued to increase and were significantly larger in EwW quail, suggesting compensatory hypertrophy. Furthermore, apoptosis measured by terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick-end labeling analysis was higher in EwWs than in CTs on embryonic day 15 and postnatal day 4 (D4). Similarly, plasma glucocorticoid (corticosterone) was higher (P<0.01) on D4 in EwW quail. These results suggest that although nephrogenic activity is high in low-nutrition quail during the perinatal period, delayed development and increased apoptosis may result in a lower number of mature nephrons. Damaged or incompletely mature mesangium may trigger glomerular injury, leading in later life to nephrosclerosis. The present study shows that birds serve as a model for 'fetal programming,' which appears to have evolved phylogenetically early.

Fetal ultrasound measurements and associations with postnatal outcomes in infancy and childhood: a systematic review of an emerging literature

BACKGROUND

Several hypotheses predict that faltering fetal growth is an antecedent for common non-communicable diseases. This is the first systematic review of an emerging literature linking antenatal fetal measurements to postnatal outcomes.

METHODS

Electronic databases (OVID, EMBASE and Google Scholar) and cohort study websites were searched in July 2014. Studies were selected which examined associations between antenatal fetal ultrasound measurements and postnatal outcomes. Neonatal outcomes, e.g. premature delivery, were not included.

RESULTS

There were 23 papers identified from cohorts in Western countries, including 11 from a single cohort. Four papers reported outcomes in children aged over 6 years. Small, but not large, for gestational age (SGA) was associated with adverse outcomes except for one study where individuals with the lightest or heaviest estimated fetal weight risk were at increased risk for autistic spectrum disorder. The magnitude of associations was modest, e.g. each z score reduction in fetal size was associated with 10-20% increased risk for delayed development or a 1 mm Hg increase in blood pressure. Both growth acceleration and deceleration were both associated with adverse outcomes.

CONCLUSIONS

There is consistency for antenatal SGA and growth deceleration being associated with adverse outcomes determined in early childhood. Accelerating fetal growth was associated with both advantageous and disadvantageous outcomes, and this is consistent with the concept of predictive adaptive responses where exposure to a postnatal environment which was not anticipated predisposes the fetus to adverse health.

Maternal malnutrition and placental insufficiency induce global downregulation of gene expression in fetal kidneys

Malnutrition during pregnancy causes intrauterine growth restriction and long-term changes in the offspring's physiology and metabolism. To explore molecular mechanisms by which the intrauterine environment conveys programming in fetal kidneys, an organ known to undergo substantial changes in many animal models of late gestational undernutrition, we used a microswine model of maternal protein restriction (MPR) in which sows were exposed to isocaloric low protein (LP) diet during late gestation/early lactation to encompass the bulk of nephrogenesis. To define general v. model-specific effects, we also used a sheep model of placental insufficiency. In kidneys from near-term fetal and neonatal microswine LP offspring, per cell levels of total RNA, poly(A)+ mRNA and transcripts of several randomly chosen housekeeping genes were significantly reduced compared to controls. Microarray analysis revealed only a few MPR-resistant genes that escape such downregulation. The ratio of histone modifications H3K4m3/H3K9m3 (active/silenced) was reduced at promoters of downregulated but not MPR-resistant genes suggesting that transcriptional suppression is the point of control. In juvenile offspring, on a normal diet from weaning, cellular RNA levels and histone mark patterns were recovered to near control levels, indicating that global repression of transcription is dependent on ongoing MPR. Importantly, cellular RNA content was also reduced in ovine fetal kidneys during placental insufficiency. These studies show that global repression of transcription may be a universal consequence of a poor intrauterine environment that contributes to fetal restriction.

Perinatal growth restriction decreases diuretic action of furosemide in adult rats

Perinatal growth restriction programs higher risk for chronic disease during adulthood via morphological and physiological changes in organ systems. Perinatal growth restriction is highly correlated with a decreased nephron number, altered renal function and subsequent hypertension. We hypothesize that such renal maladaptations result in altered pharmacologic patterns for life. Maternal protein restriction during gestation and lactation was used to induce perinatal growth restriction in the current study. The diuretic response of furosemide (2mg/kg single i.p. dose) in perinatally growth restricted rats during adulthood was investigated. Diuresis, natriuresis and renal excretion of furosemide were significantly reduced relative to controls, indicative of decreased efficacy. While a modest 12% decrease in diuresis was observed in males, females experienced 26% reduction. It is important to note that the baseline urine output and natriuresis were similar between treatment groups. The in vitro renal and hepatic metabolism of furosemide, the in vivo urinary excretion of the metabolite, and the expression of renal drug transporters were unaltered. Creatinine clearance was significantly reduced by 15% and 19% in perinatally growth restricted male and female rats, respectively. Further evidence of renal insufficiency was suggested by decreased uric acid clearance. Renal protein expression of sodium-potassium-chloride cotransporter, a pharmacodynamic target, was unaltered. In summary, perinatal growth restriction could permanently imprint pharmacokinetic processes affecting drug response.

Perinatal programming of childhood asthma: early fetal size, growth trajectory during infancy, and childhood asthma outcomes

The “fetal origins hypothesis” or concept of “developmental programming” suggests that faltering fetal growth and subsequent catch-up growth are implicated in the aetiology of cardiovascular disease. Associations between reduced birth weight, rapid postnatal weight gain, and asthma suggest that there are fetal origins to respiratory disease. The present paper first summarises the literature relating birth weight and post natal growth trajectories to asthma outcomes. Second, issues regarding the interpretation of antenatal fetal ultrasound measurements are discussed. Finally, recent reports linking antenatal measurement and growth trajectory to early childhood asthma outcomes are discussed. Understanding the nature and timing of factors which influence antenatal growth may give important insight into the antecedents of early-onset asthma with implications for interventions.

Urinary neutrophil gelatinase-associated lipocalin at birth predicts early renal function in very low birth weight infants

Preterm infants are exposed to conditions that can impair renal function. We evaluated the ability of serum and urinary neutrophil gelatinase-associated lipocalin (sNGAL and uNGAL) to predict renal function in the first weeks of life. From September 2008 to July 2009, infants weighing ≤1500 g at birth with no major congenital anomalies or sepsis were eligible. We measured sNGAL and uNGAL levels at birth. To evaluate renal function, we determined changes in serum creatinine (sCreat) and estimated GFR (eGFR) from birth to d 21. Forty neonates (mean GA, 27 ± 2 wk) completed the study. Renal function improved in 32 of 40 (80%) infants (normal renal function, NRF group) (sCreat, from 0.97 ± 0.2 to 0.53 ± 0.13 mg/dL; eGFR, from 15.3 ± 4.1 to 28.6 ± 7.9 mL/min), whereas renal function worsened in 8 of 40 (20%) infants (impaired renal function, IRF group) (sCreat, from 0.71 ± 0.27 to 0.98 ± 0.43 mg/dL; eGFR from 23 ± 14.7 to 16.4 ± 9.1 mL/min). The uNGAL/urinary creatinine (uCreat) ratio at birth was higher in the IRF group (31.05 ng/mg) than the NRF group (6.0 ng/mg), and uNGAL was significantly higher in IRF group, detecting IRF with a cutoff of 100 ng/mL. uNGAL levels at birth may have a predictive role in very LBW (VLBW) infants.

Reproductive medicine and inheritance of infertility by offspring: the role of fetal programming

OBJECTIVE

To summarize the molecular processes involved in fetal programming, to describe how assisted reproduction technologies (ART) may affect the epigenetic pattern of the embryo, and to highlight the current knowledge of the role of perinatal events in the subsequent development of reproductive pathology affecting infertile patients.

DESIGN

A literature review of fetal programming of adulthood gynecologic diseases and ART. A Medline search was performed with the following keywords: (fetal programming OR epigenetics OR methylation OR acetylation) AND (IVF OR ART) AND (gynecology). Articles up to October 2010 were selected. Articles and recent reviews were classified by human and animals studies and also according to their experimental or observational design.

SETTING

University hospital research center.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

None.

RESULT(S)

Data from experimental animal models and case-control studies support the potential effect of ART in changing methylation patterns in gametes and embryos. However, these findings are not supported by population studies or experimental studies performed in human gametes/embryos. Experimental and epidemiologic studies support the hypothesis that some adult gynecologic diseases causing infertility may have a fetal origin.

CONCLUSION(S)

Although it seems clear that some adult gynecologic diseases causing infertility may have a fetal origin, there is insufficient evidence to confirm that ART is the origin of later onset, adulthood diseases. Further research in this field must be conducted.

Perinatal nutrient restriction reduces nephron endowment increasing renal morbidity in adulthood: a review

Perinatal malnutrition has been included among the causes of renal disease in adulthood. Here, we consider the relationships between early supply of specific nutrients (such as protein, fat, vitamins and electrolytes) and renal endowment. Prenatal and postnatal nutrition mismatch is also discussed. In addition, this article presents the role of nutrition of both mothers and pre-term infants on nephron endowment, with final practical considerations.

Fetal origins of renal disparities

Epidemiologic studies of populations continue to emerge showing that early-life factors influence the risk of developing several chronic diseases of adulthood. Susceptibility to environmental factors is particularly problematic during renal development, which is not complete until 36 weeks of gestation. Environmental deprivation may lead to adaptations including early growth restriction, whereas late insults may alter the kidney during the final stages of development. Because disparities among those who are more likely to have low birth weight mirrors the disparities observed among those more likely to develop kidney-related disorders, fetal origins have been presumed to explain some of the observed disparities. Although current empiric evidence supports a link between fetal programming and childhood/adult kidney disease, affected pathways may vary by race.

Maternal nutrient restriction during pregnancy differentially alters the unfolded protein response in adipose and renal tissue of obese juvenile offspring

Maternal diet during pregnancy can program an offspring's risk of disease in later life. Obesity adversely alters renal and adipose tissue function, resulting in chronic kidney disease and insulin resistance, respectively, the latter associated with dysregulation of the unfolded protein response (UPR). In view of the current obesity epidemic, we explored the combined effects of in utero early- to midgestational nutrient restriction and postnatal obesity on the UPR in ovine juvenile offspring. Nutrient restriction was coincident with fetal kidney development but prior to exponential adipose tissue deposition. Nutrient restricted (NR) and normal diet (control) offspring were exposed to an obesogenic environment throughout adolescence, resulting in similar degrees of juvenile obesity. NR offspring showed enhanced adipose tissue dysregulation characterized by activation of the UPR, perturbed insulin signaling, and marked inflammation, as demonstrated by increased abundance of crownlike structures and proinflammatory genes. Conversely, in renal tissue NR offspring had marked attenuation of cellular stress and inflammation evident as reduced activation of the UPR, down-regulation of proinflammatory genes, and less histological damage. In conclusion, obesity-related activation of the UPR can be determined by the in utero nutritional environment, demonstrating organ-specific effects dependent on the developmental phase targeted within the fetus.

Birth weight and stages of CKD: a case-control study in an Australian population

BACKGROUND

In view of recent reports of the relationship of kidney disease to birth weight, we evaluate the relationship between birth weight and chronic kidney disease (CKD), including end-stage kidney disease, in Australian adults.

STUDY DESIGN

A case-control study.

SETTING & PARTICIPANTS

Patients attending the nephrology department at a major metropolitan hospital in Australia were asked to recall their birth weight, excluding those with structural kidney abnormalities. Two controls for each patient, matched for sex and within 5 years of age, were selected from participants from the Australian Diabetes, Obesity and Lifestyle (AusDiab) Study, who had also been asked to report their birth weight.

PREDICTOR

Birth weight in kilograms.

OUTCOMES & MEASUREMENTS

CKD and stages were defined using the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative classification, proteinuria as a marker of kidney damage, and glomerular filtration rate estimates, by using the Modification of Diet in Renal Disease Study equation.

RESULTS

Of 189 patients with CKD who reported their birth weights for whom controls were identified, 106 were men. Mean age was 60.3 +/- 15 (SD) years. Mean birth weight overall was 3.27 +/- 0.6 versus 3.46 +/- 0.6 kg for their controls (P < 0.001), and proportions with birth weights less than 2.5 kg were 12.2% and 4.4% (P < 0.001). In patients with CKD, 22.8%, 21.7%, 18%, and 37.6% were in CKD stages 2 (n = 43), 3 (n = 41), 4 (n = 34), and 5 (n = 71), respectively. Birth weights by CKD stage and their AusDiab controls were as follows: stage 2, 3.38 +/- 0.52 versus 3.49 +/- 0.52 kg; P = 0.2; stage 3, 3.28 +/- 0.54 versus 3.44 +/- 0.54 kg; P = 0.1; stage 4, 3.19 +/- 0.72 versus 3.43 +/- 0.56 kg; P = 0.1; and stage 5, 3.09 +/- 0.65 versus 3.47 +/- 0.67 kg; P < 0.001. Differences in birth weights applied to women and men and people younger than 60 and 60 years and older and were present in the major "causal" categories of renal disease.

LIMITATIONS

Birth weight is by self-recall with a significant nonresponse rate to the questionnaire in both cases and controls.

CONCLUSIONS

Urban Australian patients with CKD had lower birth weights than their matched Australian controls. In addition, the more advanced the CKD stage, the lower the birth weight. Thus, lower birth weights appear to predispose to CKD and to its progression. Among possible explanations is the documented association between birth weight and nephron number.

Interrater reliability and effect of state on blood pressure measurements in infants 1 to 3 years of age

OBJECTIVE

The objective of this study was to determine the interrater variability and effect of state on systolic blood pressure measurements in infants </=3 years of age.

METHODS

Study 1 examined interrater variability, determined by interclass correlation coefficient for 2 raters, and the effect of state on systolic blood pressure measurements in infants at 1, 2, and 3 years. Study 2 examined the variability of duplicate systolic blood pressure measurements by a single rater determined by interclass correlation coefficient and effect of state in 120 infants at 1, 2, and 3 years. Systolic blood pressure was defined as the Doppler-amplified sound corresponding to the first Korotkoff sound using a sphygmomanometer with appropriate cuff size. State was scored as follows: 1, sleeping; 2, awake and calm; 3, awake and fussy/restless; and 4, awake and vigorously crying/screaming.

RESULTS

In study 1, the overall interclass correlation coefficient for systolic blood pressure was 0.81 and decreased when state varied between raters. When compared with a calm state 1 and/or 2 at both measurements, noncalm state 3 and/or 4 at both measurements was associated with an increase in systolic blood pressure. Although state was similar in infants born at </=36 and >36 weeks' gestational age, the former had a systolic blood pressure 13.0 +/- 14 mm Hg greater than the 50th centile for age and gender versus 2.4 +/- 12 mmHg for those >36 weeks' gestation. In study 2, the interclass correlation coefficient for repeated measurements by a single rater was 0.85, and noncalm state at both measurements was associated with an elevated systolic blood pressure.

CONCLUSIONS

Systolic blood pressure can be accurately measured in the first 3 years after birth, but state modifies systolic blood pressure and must be determined at the time of measurement. Infants born at </=36 weeks' estimated gestational age may be at risk for an elevated systolic blood pressure, but this requires additional study.

Urine concentration and avian aquaporin water channels

Although birds and mammals have evolved from primitive tetrapods and advanced divergently, both can conserve water by producing hyperosmotic urine. Unique aspects in the avian system include the presence of loopless and looped nephrons, lack of the thin ascending limb of Henle's loop, a corticomedullary osmotic gradient primarily consisting of NaCl without contribution of urea, and significant postrenal modification of final urine. The countercurrent multiplier mechanism operates between the descending and ascending limbs of Henle via recycling of a single solute (NaCl) with no water accompaniment, forming an osmotic gradient along the medullary cone. Bird kidneys and developing rat kidneys share morphological and functional characteristics. Avian kidneys express aquaporin (AQP) 1, 2, and 4 homologues that share considerable homology with mammalian counterparts, but their distribution and function may not be the same. AQP2 expression in Japanese quail (q) evolves in the collecting duct of early metanephric kidneys and continues to increase in intensity and distribution during nephrogenesis and maturation. qAQP2 mRNA and protein are increased by arginine vasotocin (avian ADH), but vasotocin-induced enhancement of cAMP production and water permeability are less marked than in mammalian kidneys. Nephrogenesis is delayed by insufficient nutrition in avian embryos and newborns and results in fewer nephrons and an impaired water balance in adults. Diabetes insipidus quail with homozygous autosomal recessive mutation and an unaffected vasotocin system have low AQP2 expression, underdeveloped medullary cones. Comparative studies will provide important insight into integrative, cellular, and molecular mechanisms of epithelial water transport and its control by humoral, neural, and hemodynamic mechanisms.

Aquaporin-2 water channel in developing quail kidney: possible role in programming adult fluid homeostasis

Avian kidneys have loopless and looped nephrons; a countercurrent multiplier mechanism operates in the latter by NaCl recycling. We identified an aquaporin-2 (AQP2) homolog in apical/subapical regions of cortical and medullary collecting duct (CD) cells in kidneys of Japanese quail (q), Coturnix japonica. We investigated whether undernutrition during the embryonic/maturation period retards kidney and AQP2 development in quail and programs impaired volume regulation in adults. Protocols included 1) time course and 2) effects of 5-10% egg white withdrawal (EwW) or 48-h post-hatch food deprivation (FD) on nephron growth and qAQP2 mRNA expression, and 3) effects of EwW and FD on qAQP2 mRNA responses to 72-h water deprivation in adults. In metanephric kidneys, qAQP2 mRNA is expressed in medullary CDs at embryonic day 10; distribution and intensity increase during maturation. The number and size of glomeruli continue to increase after birth, whereas nephrogenic zones decrease. In EwW embryos, qAQP2 mRNA expression is initially delayed, then restored; birth weight and hatching rate are lower than in controls. Adults from EwW embryos and FD chicks have fewer (P < 0.01) glomeruli. Water deprivation reduces body weight more in EwW birds than in controls. The results suggest that qAQP2 evolved in metanephric kidneys and that undernutrition may retard nephrogenesis, leading to impaired adult water homeostasis.

Expression of matrix metalloproteinases MMP-2 and MMP-9 is altered during nephrogenesis in fetuses from diabetic rats

Remodeling of extracellular matrix (ECM) is an important physiological feature of normal growth and development. Recent studies have emphasized the role of matrix metalloproteinases (MMP-2 and MMP-9) in normal mouse nephrogenesis. We have demonstrated previously in the rat that in utero exposure to maternal diabetes impairs renal development leading to a 30% reduction in the nephron number. Transforming growth factor-beta1 (TGF-beta1) and connective tissue growth factor (CTGF) are known to mediate high glucose effects on matrix degradation. The aim of the present study was to address the expression of type IV collagenase and TGF-beta1/CTGF systems in rat kidney during normal development and after in utero exposure to maternal diabetes. Both MMP-2 and MMP-9 mRNA metanephric expressions and activities were dramatically downregulated in kidneys issued from diabetic fetuses and in metanephros cultured in the presence of high glucose concentration. TGF-beta1 and CTGF expressions were significantly enhanced in diabetic fetal kidneys and in high glucose cultured metanephroi. Conditioned media obtained from metanephroi grown with high glucose concentration upregulated functional TGF-beta activity in transfected ATDC5 cells. In conclusion, in impaired nephrogenesis resulting from in utero exposure to maternal diabetes, alteration of both type IV collagenase and TGF-beta1/CTGF systems may lead to abnormal remodeling of ECM, which may, in turn, induce defects in ureteral bud branching leading to the observed reduction in the nephron number with consequences later in life: progression of chronic renal disease and hypertension.

Is hypertension a tissue perfusion disorder? Implications for renal and myocardial perfusion

Structural alterations in the microcirculation form a major link between hypertension and target organ damage. More than 60% of the overall peripheral resistance of the circulatory system arises at the level of the microcirculation. The primary function of the microcirculation is to supply oxygen and nutrients to tissues. In hypertension, remodelling of the microvascular vessels occurs, leading to an early, functional then anatomical reduction in the number of arterioles or capillaries in a given vascular bed. Such changes have been seen in the structure and density of the microvasculature of different target organs such as the myocardium and the kidneys. In hypertension, capillary rarefaction induces an increase in blood pressure, a relative decrease in tissue perfusion and an increased cardiovascular risk. Recent in-vivo non-invasive techniques for exploring the human microcirculation have allowed the detection of myocardial and renal microvascular impairment in hypertensive patients. In comparative therapeutic studies, antihypertensive drugs have been shown to have different capacities for preventing or reversing changes to the microvasculature of affected organs.