ConditionKidneys & urinary tract
Kidney Disease Due to Longstanding Hypertension (Hypertensive Nephropathy)
Kidney disease due to longstanding hypertension, also called hypertensive nephropathy or hypertensive nephrosclerosis, is gradual kidney damage caused by years of high blood pressure. Raised pressure thickens and narrows the small arteries in the kidneys, so filtering units scar and are lost. It is the second leading cause of kidney failure in the US after diabetes. It is usually silent until advanced, so blood and urine tests are essential. Controlling blood pressure slows or stops progression.
Also called: Hypertensive nephropathy, hypertensive kidney disease, hypertensive nephrosclerosis, chronic kidney disease due to hypertension
At a glance
- What it is
- Chronic kidney damage from years of uncontrolled or poorly controlled high blood pressure.
- Who is at risk
- Long-standing hypertension, older age, Black Americans (with APOL1 gene variants), diabetes, obesity, smoking.
- Symptoms
- Usually none early; later fatigue, swelling, foamy urine, poor appetite, itching.
- Tests
- eGFR (blood creatinine), urine albumin-to-creatinine ratio, ultrasound.
- Treatment
- Blood pressure control (often with ACE inhibitors or ARBs), SGLT2 inhibitors, low salt, heart risk reduction.
When to get help
Call 911 or go to the ER
- Blood pressure of 180/120 mmHg or higher with chest pain, shortness of breath, severe headache, confusion, vision changes or weakness: call 911 or your local emergency number
- Very little or no urine, with swelling and breathlessness
See a doctor within a day or two
- Blood pressure of 180/120 mmHg or higher without symptoms: recheck after 5 minutes and contact your doctor the same day
- Rapidly worsening swelling of the legs, face or belly, or shortness of breath lying flat
- A potassium result reported as high, or muscle weakness and palpitations on kidney or blood pressure medicines
Book a routine appointment
- High blood pressure without a kidney check (eGFR and urine albumin) in the past year
- Foamy urine, ankle swelling or nighttime urination that is new
- Blood pressure readings that stay above your target
How high blood pressure damages the kidneys
High blood pressure affects the kidneys through their blood supply. Each kidney contains about a million tiny filters (glomeruli) fed by small arteries. Years of high pressure cause:
- thickening and stiffening of the small arteries (arteriolosclerosis)
- reduced blood flow and oxygen to the filters
- scarring of filters and surrounding tissue (nephrosclerosis)
As filters are lost, the remaining ones work harder, which damages them further. Meanwhile, damaged kidneys hold onto salt and water and release hormones that raise blood pressure, creating a vicious cycle.
Not everyone with high blood pressure develops kidney disease. Genetics, especially APOL1 gene variants common in people of West African ancestry, help explain why Black Americans have a much higher risk of kidney failure attributed to hypertension.
Symptoms
Early hypertensive kidney disease causes no symptoms. As chronic kidney disease advances:
- tiredness and weakness
- swelling of the ankles, feet or around the eyes
- foamy urine (protein)
- needing to urinate at night
- poor appetite, nausea, metallic taste
- itching, muscle cramps
- feeling cold, trouble concentrating
- shortness of breath from fluid or anemia
Diagnosis
Hypertensive nephropathy is often a diagnosis of pattern and exclusion:
- eGFR: a blood test estimating kidney filtering ability; below 60 for 3 months or more indicates CKD
- urine albumin-to-creatinine ratio (UACR): detects albumin leaking into urine, an early sign of damage
- urinalysis: blood or cells suggest other kidney diseases
- kidney ultrasound: typically shows symmetrically small kidneys in advanced disease
- eye exam: changes in retinal vessels reflect long-standing hypertension
- tests to exclude other causes: diabetes (diabetic nephropathy), renal artery stenosis, glomerulonephritis, polycystic kidney disease
- kidney biopsy is rarely needed
CKD stages
| Stage | eGFR (mL/min/1.73 m²) | Description |
|---|---|---|
| 1 | 90 or more | Normal function with signs of damage |
| 2 | 60 to 89 | Mildly reduced |
| 3a | 45 to 59 | Mild to moderately reduced |
| 3b | 30 to 44 | Moderately to severely reduced |
| 4 | 15 to 29 | Severely reduced |
| 5 | Under 15 | Kidney failure |
Treatment
Blood pressure control
The most important treatment. Many guidelines advise a systolic target below 120 to 130 mmHg for people with CKD, if tolerated; your doctor will set a personal target.
- ACE inhibitors or ARBs: preferred, especially with albumin in the urine, because they lower pressure inside the kidney filters
- diuretics, calcium channel blockers and others as needed; most people need two or more medicines
- home blood pressure monitoring
Kidney-protective medicines
- SGLT2 inhibitors (such as dapagliflozin and empagliflozin) slow CKD progression even without diabetes
- finerenone in people with type 2 diabetes and albuminuria
- statins to reduce heart disease risk
Lifestyle
- limit sodium to under about 2,300 mg a day (lower if advised)
- follow a heart-healthy eating pattern such as DASH, adjusted for potassium and protein by your kidney team
- stop smoking
- stay active and reach a healthy weight
- limit alcohol
- avoid NSAIDs such as ibuprofen and naproxen, which can harm kidneys
Advanced disease
Management of anemia, bone and mineral problems, acid levels and potassium, and preparation for dialysis or a kidney transplant if kidney failure approaches.
Complications
- progression to kidney failure
- heart failure, heart attack and stroke: people with CKD are more likely to die of heart disease than to need dialysis
- anemia, bone disease, high potassium
Prevention
- check blood pressure regularly and treat high readings
- get yearly eGFR and urine albumin tests if you have hypertension
- take blood pressure medicines consistently, even when you feel fine
Frequently asked questions
Can high blood pressure cause kidney disease?
Yes. Over years, high blood pressure damages the small arteries in the kidneys, reducing blood flow and scarring the filters. It is the second most common cause of kidney failure in the US. Good blood pressure control greatly reduces the risk.
What are the symptoms of kidney damage from high blood pressure?
Early damage usually causes no symptoms. Later signs include fatigue, swelling of ankles or around the eyes, foamy urine, frequent nighttime urination, poor appetite, itching and muscle cramps. Blood and urine tests detect damage long before symptoms.
Can kidney damage from high blood pressure be reversed?
Scarring cannot be reversed, but progression can be slowed or stopped by controlling blood pressure, using kidney-protective medicines such as ACE inhibitors, ARBs and SGLT2 inhibitors, reducing salt and avoiding kidney-harming drugs.
What blood pressure is best for kidney disease?
Many guidelines suggest a systolic blood pressure below 120 to 130 mmHg for people with chronic kidney disease, if it can be achieved safely. Your doctor will set a target based on your age, other conditions and side effects.
How is hypertensive nephropathy diagnosed?
It is diagnosed with blood tests (eGFR), urine albumin tests and often a kidney ultrasound in someone with long-standing high blood pressure, after ruling out other causes such as diabetes. A kidney biopsy is rarely needed.
Sources
This guide was written from current patient and clinical guidance, including:
- National Kidney Foundation: High Blood Pressure and Chronic Kidney Disease
- NIDDK: High Blood Pressure and Kidney Disease
- KDIGO: Clinical Practice Guideline for the Management of Blood Pressure in CKD
- American Heart Association: How High Blood Pressure Can Lead to Kidney Damage
- US Renal Data System (USRDS): Annual Data Report