Abstract-It is currently unclear whether hypertensive nephrosclerosis (HN), usually diagnosed solely on clinical grounds, is a relevant cause of end-stage renal disease. We biopsied 81 hypertensive outpatients (blood pressure Ն160/ 95 mm Hg) with moderate renal insufficiency, who were referred to our service from 1988 to 1998. Patients with known causes of hypertension, systemic disorders, rheumatic disease, or nephrotic syndrome were excluded. In 65% of patients, HN was the sole histological abnormality associated with renal dysfunction. Benign nephrosclerosis (BN), defined as isolated arteriolar hyalinosis and/or intimal fibrosis, was found in 18 HN patients (22%), whereas malignant nephrosclerosis (MN), denoted mainly by myointimal cell proliferation, appeared in 35 HN patients (43%). Previously undiagnosed primary nephritis (PN) was found in 13 patients (16%), whereas focal and segmental glomerulosclerosis, which might be either primary or secondary to hypertension, appeared in 15 patients (19% Usually, the diagnosis of HN is entirely made on clinical grounds, without renal biopsy or any evidence that hypertension actually preceded renal disease. Thus, HN can be easily mistaken for primary or ischemic nephropathies, which may also exhibit an insidious nature. Only 2 large biopsy-based studies of HN have been reported so far. Zucchelli and Zuccala 8 showed "true" HN in only 48% of 56 white patients clinically diagnosed as such. Fogo et al 9 showed an 85% agreement between clinical and histological diagnoses of HN in African Americans.We performed a 10-year follow-up of 81 hypertensives with impaired renal function and no clinical evidence of primary or ischemic renal disease. We could thus evaluate the frequency of HN among them and whether HN can be safely diagnosed on a clinical basis.
Methods
PatientsBetween 1988 and 1998, a selected, nonsystematic cohort of 90 hypertensive patients, referred to the Hypertension Clinic of the Renal Division, Department of Clinical Medicine, University of São Paulo, was investigated. Inclusion criteria were arterial hypertension and renal insufficiency. A patient was determined to have arterial hypertension if (1) systolic blood pressure (SBP) was Ն160 mm Hg and/or diastolic blood pressure (DBP) was Ն95 mm Hg, following the then most recent World Health Organization guidelines, 10 or (2) there was a persistent need for antihypertensives. Blood pressure was determined as the average of 2 sphygmomanometric measurements, taken in the seated position after a 5-minute rest. Renal insufficiency was defined by serum creatinine concentration (S creat ) Ͼ133 mol/L (1.5 mg/dL). Exclusion criteria were (1) renal artery stenosis (diagnosed by renal arteriography); (2) other definite causes of hypertension; (3) diabetes mellitus; (4) immune-mediated disease; (5) heart failure (stages III and IV); (6) liver disease; (7) nephrotic syndrome, defined by proteinuria Ͼ3.5 g/d, hypoalbuminemia, edema, and hypercholesterolemia; (8) polycystic nephropathy; (9) urinary obstruction; (10) pregnancy...
