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Cause, Consequence or confounding? The kidney in hypertension

Journal of Human Hypertension volume 33, pages 639–640 (2019)Cite this article

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Kidney disease has been widely accepted as a cause of hypertension, though whether it is a consequence of hypertension is still debated. Indeed, trial evidence does not support the lowering of blood pressure as being protective for the kidneys. Recent epidemiological evidence still supports elevated blood pressure as a risk factor for worsening kidney function. Notwithstanding these issues, treatment of hypertension is mandated more for prevention of cardiovascular outcomes, and the safety of this approach with respect to kidneys should be considered more reassuring than any potential benefit.

In 1836, Richard Bright noted left ventricular hypertrophy in his initial description of kidney disease, and presciently speculated that the altered quality of the blood in kidney disease affected the peripheral vasculature [1]. Fast forward 2 centuries to Guyton’s description of the kidney’s infinite feedback gain property for pressure control [2]. Thus the kidney’s role in causing hypertension is well established, but what of the role of hypertension in causing kidney disease or worsening kidney function? Indeed, hypertension is widely accepted as an independent risk factor for adverse vascular outcomes, including stroke, heart failure, ischemic heart disease, and end-stage kidney disease (ESKD). Epidemiological evidence from large population cohorts indicate that this risk follows a biological gradient and increases with the level of systolic blood pressure (BP) [3, 4]. This increase in risk is noticeable from the level of the SBP > 120 mmHg, and it is particularly steep above the level of SBP > 140 mmHg. However, it is strongest for stroke, less pronounced for heart failure, and particularly weak for the development of ESKD. For example, in a historical study cohort of 316,675 patients with no evidence of chronic kidney disease (CKD) (based on a normal glomerular filtration rate [GFR] > 60 ml/min/1.73 m2 and a bland urinanalysis) the adjusted relative risk (RR) of developing ESKD was 1.62 (95% confidence interval [CI], 1.27–2.07) for blood pressures of 120 to 129/80 to 84 mmHg, 1.98 (95% CI, 1.55–2.52) for 130 to 139/85 to 89 mmHg, 2.59 (95% CI, 2.07–3.25) for 140 to 159/90 to 99 mmHg, 3.86 (95% CI, 3.00–4.96) for 160 to 179/100 to 109 mmHg, 3.88 (95% CI, 2.82–5.34) of 180 to 209/110 to 119 mmHg, and 4.25 (95% CI, 2.63–6.86) of 210/120 mmHg [3]. This was in comparison to initial blood pressure < 120/80 mmHg, and over a period of 30 years.

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Authors and Affiliations

  1. Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Canada

    Marcel Ruzicka & Swapnil Hiremath

  2. Chronic Diseases Program, Ottawa Hospital Research Institute, Ottawa, Canada

    Marcel Ruzicka

  3. Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada

    Swapnil Hiremath

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Correspondence to Swapnil Hiremath.

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Ruzicka, M., Hiremath, S. Cause, Consequence or confounding? The kidney in hypertension. J Hum Hypertens 33, 639–640 (2019). https://doi.org/10.1038/s41371-019-0199-6

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