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PATHOGENESIS
Hypertension is a frequent finding in both acute and chronic kidney disease, particularly with glomerular or vascular disorders [
1]. However, the incidence of hypertension and its pathogenesis vary with the type of renal disease and its duration.
Acute glomerular disease — Patients with acute glomerular disease, such as poststreptococcal glomerulonephritis or membranous nephropathy, tend to be volume expanded and edematous due to sodium retention [
2]. As a result, the elevation in blood pressure is primarily due to fluid overload, leading to suppression of the renin-angiotensin system and enhanced release of atrial natriuretic peptide [
3]. Although these changes are most prominent with advanced disease, the incidence of hypertension is increased even in patients with a normal serum creatinine concentration [
4]. Both a familial predisposition to hypertension and subclinical volume expansion are thought to be important in this setting.
Experimental studies of the nephrotic syndrome or glomerulonephritis suggest that sodium retention in these disorders is due to increased reabsorption in the collecting tubules [
5], which is also the site of action of atrial natriuretic peptide and the related renal hormone urodilatin. (See
"Natriuretic hormones: Atrial peptides and ouabain-like hormone".)
Two different abnormalities in collecting tubule function have been identified in glomerular disease, both of which could increase sodium reabsorption:
- Relative resistance to atrial natriuretic peptide, due at least in part to more rapid degradation of the second messenger cyclic GMP (guanosine monophosphate) by the enzyme phosphodiesterase [4]. Infusion of a phosphodiesterase inhibitor largely reverses this defect and restores the normal natriuretic response to volume expansion.
- Increased activity of the Na-K-ATPase pump in the cortical collecting tubule but not other nephron segments [6]. This pump provides the energy for active sodium transport by pumping reabsorbed sodium out the cell into the peritubular capillary.
