The role of systemic hypertension in the progression of nondiabetic renal disease

Background. A role for hypertension in the progression of renal disease has been convincingly shown in experimental animals only. In human studies, th e relation between hypertension and progression is difficult to demonstrate due to several confounding factors: age, gender, race; the difficult choic e of blood pressure (BP) parameters that correlate with progression; the ab normal circadian BP pattern; and the many nonhemodynamic factors of progres sion. An important role for hypertension in progressive nondiabetic renal d isease has been suggested by observational studies and clinical trials orig inally intended to evaluate the effect of dietary protein restriction on pr ogression. In addition, several studies, summarized by a recent meta-analys is, have shown that pharmacological agents which lower both BP and proteinu ria, mainly the angiotensin-converting enzyme inhibitors (ACEI), significan tly slow the rate of progression in these diseases. Methods. In this article we review the effect of lowering BP on the progres sion of nondiabetic chronic renal disease, the patient characteristics that are associated with a greater or lesser benefit of blood pressure reductio n, and the choice of antihypertensive regimens associated with better outco mes in patients with renal disease. Results. Lower levels of achieved BP are associated with a slower decline i n renal function, both in patients with and without proteinuria. ACEI are e ffective BP lowering agents and are associated with better preservation of renal function as opposed to antihypertensive regimens without ACEI. This p rotective effect of ACEI is in addition to their BP and urine protein lower ing effects. The protective effect of ACEI on renal function is more pronou nced in patients with proteinuria. Conclusion. In patients with nondiabetic renal disease and proteinuria, the risk of progression can be minimized by lowering both BP and proteinuria. ACEI have an additional beneficial effect.