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Abstract—Unlike the majority of patients with uncomplicated hypertension in whom minimal renal damage develops in
the absence of severe blood pressure (BP) elevations, patients with diabetic and nondiabetic chronic kidney disease
(CKD) exhibit an increased vulnerability to even moderate BP elevations. Investigations in experimental animal models
have revealed that this enhanced susceptibility is a consequence of an impairment of the renal autoregulatory
mechanisms that normally attenuate the transmission of elevated systemic pressures to the glomeruli in uncomplicated
hypertension. The markedly lower BP threshold for renal damage and the steeper slope of relationship between BP and
renal damage in such states necessitates that BP be lowered into the normotensive range to prevent progressive renal
damage. When BP is accurately measured using radiotelemetry in animal models, the renal protection provided by
renin-angiotensin system (RAS) blockade is proportional to the BP reduction with little evidence of BP-independent
protection. A critical evaluation of the clinical data also suggests that the BP-independent renoprotection by RAS
blockade has been overemphasized and that achieving lower BP targets is more important than the selection of
antihypertensive regimens. However, achievement of such BP goals is difficult in CKD patients without aggressive
diuresis, because of their proclivity for salt retention. The effectiveness of RAS blockers in lowering BP in patients who
have been adequately treated with diuretics, along with their potassium-sparing and magnesium-sparing effects,
provides a more compelling rationale for the use of RAS blockade in the treatment of CKD patients than any putative
BP-independent renoprotective superiority. (Hypertension. 2004;44:595-601.)
Key Words: nephrosclerosis 䡲 autoregulation 䡲 telemetry 䡲 antihypertensive agents
䡲 renin-angiotensin system 䡲 glomerulosclerosis
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Received August 5, 2004; first decision August 11, 2004; revision accepted September 3, 2004.
From Loyola University Medical Center and Edward Hines Jr. VA Hospital, Maywood, Ill.
Correspondence to Anil K. Bidani, MD, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153. E-mail abidani@lumc.edu
© 2004 American Heart Association, Inc.
Hypertension is available at http://www.hypertensionaha.org DOI: 10.1161/01.HYP.0000145180.38707.84
595
596 Hypertension November 2004
histological phenotype. Vascular pathology, considered the Figure 2. Illustration of the spectrum of pressure flow relation-
hallmark of hypertensive injury, often is not prominent in this ships in the renal vascular bed in hypertension. Pattern A repre-
setting of CKD. Instead, an accelerated segmental or global sents the normal renal autoregulatory responses observed in
glomerulosclerosis (GS) seems to be superimposed on the uncomplicated hypertension and shows the constancy of renal
blood flow (RBF) despite BP changes within the autoregulatory
intrinsic phenotype of the underlying renal disease.3,5 Never- range. Pattern B indicates the ambient renal vasodilation but
theless, recent investigations in experimental animal models preserved autoregulation after uninephrectomy. Pattern C illus-
have increased our understanding of the mechanisms that trates the impaired RBF autoregulatory responses observed in
the 5/6 renal ablation model. Pattern D shows the complete loss
underlie the observed differences in histological phenotypes of renal autoregulation in 5/6 renal-ablated rats treated with di-
and susceptibility to hypertensive renal damage illustrated in hydropyridine CCBs. Although RBF is depicted as the depen-
Figure 1. dent variable, the same relationships are expected to obtain for
PGC, given that the autoregulatory resistance changes are con-
fined to the preglomerular vasculature.
Pathophysiology of Hypertensive
Renal Damage
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renal autoregulation is additionally impaired, as seen after there is evidence that glomerular hypertrophy may be an
more severe (ⱖ75%) renal mass reduction in animals or in independent risk factor for GS.5,21,24 In addition to the
humans with diabetic or nondiabetic CKD10,17–19 (Figure 2; expected increase in wall tension (Laplace Law:
pattern C), the susceptibility to hypertensive injury is mark- tension⫽pressure⫻radius), hypertrophy of glomerular capil-
edly enhanced with the greatly reduced BP threshold for laries may also compromise their ability to withstand me-
damage and the steeper relationship between BP and renal chanical stress.25,26 It has been proposed that the glomerular
damage as illustrated in Figure 1. Additionally, such en- capillary epithelial cell (podocyte) through its interdigitating
hanced glomerular pressure transmission in the absence of foot processes provides structural support against pressures
hypertension severe enough to cause vascular injury primar- that are substantially higher than in systemic capillaries (⬇45
ily leads to accelerated GS.3,5 versus ⬇20 mm Hg). The limited replication potential of this
The clearest demonstration of this phenomenon has been terminally differentiated cell during glomerular hypertrophy
provided in the most extensively investigated model of CKD, may limit its ability to maintain physical integrity and
the rat 5/6 renal ablation model.4 – 6 Through the use of BP mechanical support during hypertensive stress.
radiotelemetry, it has been shown that the progressive GS of However, of the local mechanisms, the BP-independent
the initially normal remnant glomeruli in these rats follows tissue damage promoting effects of angiotensin II and, more
the quantitative relationships with BP shown in Figure 1 and recently, aldosterone have received the greatest empha-
predicted by Figure 2.6,17 The importance of autoregulatory sis.4,12,24,27–29 The triggering of several downstream deleteri-
capacity as a determinant of the susceptibility to hypertensive ous cellular and molecular pathways is postulated to lead to
injury is further illustrated by the effects of the dihydropyr- oxidative stress and the activation of growth factors and
idine calcium channel blockers (CCBs) in this model. Given fibrogenic mediators such as transforming growth factor-
the critical dependence of autoregulatory response on and plasminogen activator inhibitor-1. Despite the consider-
voltage-gated calcium channels, these agents, not unexpect- able in vitro data demonstrating these pathways, the primary
edly, further impair the already impaired renal autoregulation evidence to support their in vivo importance is derived from
in the 5/6 ablation model5,20 (Figure 2; pattern D). And the very large number of studies in animal models that have
predictably, CCBs also further reduce the BP threshold and claimed to show glomeruloprotection by renin-angiotensin
increase the slope of the relationship between GS and BP system (RAS) blockade and/or aldosterone antagonists over
(percent increase in GS/mm Hg in BP) such that greater GS is and beyond that achieved by “equivalent” BP reductions with
observed at any given BP elevation as compared with other antihypertensive regimens.4,24,27–30 However, when BP
untreated rats, and protection is not achieved without achiev- has been measured more continuously by radiotelemetry
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ing normotension.5,20 Conversely, if preglomerular vasodila- instead of intermittently by tail-cuff, the renoprotection can
tion and autoregulatory impairment are prevented in this be entirely accounted for by the achieved BP reductions with
model through the substitution of a low-protein diet, GS is little evidence of additional BP-independent protection.5,31,32
also ameliorated despite continued hypertension.10,21 How- This is true of both the malignant nephrosclerosis and the
ever, if CCBs are given to the low-protein diet–fed rats, renal accelerated GS models (5/6 ablation). No evidence of a shift
autoregulation is impaired and the protection against GS is to a higher BP threshold for damage or a decrease in the slope
also abolished.21 Similar adverse effects of dihydropyridine of the relationship between BP and GS is seen with RAS
CCBs, and protective effects of a low-protein diet on GS, blockade, as would be expected with significant BP-
have also been noted in the streptozotocin-induced diabetes independent protection. In this context, it is relevant to note
model.4,22 that isolated PGC measurements like isolated BP measure-
Of note, differences in autoregulatory efficiency have also ments may not accurately reflect chronic pressure exposure.
been postulated to account for some of the strain (genetic) Such limitations probably account for the lack of consistent
differences in susceptibility to hypertensive injury.5,11,23 correlations between PGC and GS,24 even in models demon-
However, it needs to be emphasized that these adverse effects strating excellent correlation with radiotelemetrically mea-
of impaired renal autoregulation on susceptibility to hyper- sured systemic BP.5,6
tensive renal damage are only observed in a vasodilated Collectively, these data suggest that the activation of
vascular bed. In a vasoconstricted bed, the consequences of downstream molecular mediators of tissue injury may not be
impaired autoregulation primarily result in a diminished exclusive to angiotensin II and/or aldosterone but may rep-
capacity to maintain renal blood flow and glomerular filtra- resent a response to tissue stress and/or injury per se. There is
tion rate (GFR) when systemic pressures are reduced, with an evidence that pressure alone can activate many of these
enhanced potential for ischemic tubulointerstitial injury. A downstream pathways,32–35 and the histological phenotype of
similar ischemic pathogenesis may underlie the tubulointer- hypertensive renal damage exhibits little difference in models
stitial injury observed in angiotensin infusion models.12 with or without overt RAS activation.3 Conversely, little
evidence of the activation of these deleterious pathways or
Local BP-Independent Determinants of renal damage is observed in the absence of elevated pressures
Tissue Susceptibility despite substantial angiotensin and aldosterone increases
Although still poorly defined, genetic or acquired differences during low salt intake, congestive heart failure, or cirrhosis,
in intrinsic structure or function may result in differences in or in the clipped kidney of the 2-kidney–1-clip model of
the severity of damage expressed at any given degree of Goldblatt hypertension.36 In fact, the administration of even
increased pressure exposure (barotrauma).5,8,11 For instance, very large amounts of exogenous aldosterone results in little
598 Hypertension November 2004
target organ damage in animals maintained normotensive on prevent malignant nephrosclerosis in patients with uncompli-
a low-salt diet. Moreover, investigations into the pathogenic cated hypertension.5,13 By contrast, BP may need to be
role of aldosterone have usually not adequately controlled for lowered well into the normotensive range in CKD patients to
changes in potassium balance, which can independently prevent additional GS. The more limited success against
impact renal damage.37 Thus, although it remains possible progressive renal disease as compared with malignant neph-
that angiotensin II and aldosterone may amplify hypertensive rosclerosis and hypertensive stroke is thus not unexpected.1,2
renal damage through BP-independent mechanisms in certain The systolic BP goal of 140 to 150 mm Hg that was
situations and/or models, definitive evidence remains to be considered acceptable until recently in patients with CKD,
obtained. because even if achieved, it might not have been low enough
to prevent continued glomerular barotrauma. The pathophys-
Unresolved Issues iology of hypertensive glomerular injury in these states
Despite the progress that has been achieved, certain funda- predicts that the more advanced the CKD (the greater the
mental issues of hypertensive target organ damage remain vasodilation and autoregulatory impairment), the lower the
unresolved. The term “BP load” is used generically because achieved BP will need to be to normalize intrarenal pressures.
the relative pathogenic importance of individual BP parame- Moreover, even transient episodes of BP elevations are
ters (mean, systolic, diastolic, pulse pressure, and BP vari- predicted to be more freely transmitted to the glomerular
ability) remains undefined.5 Although recent clinical data capillaries, suggesting the need for around-the-clock BP
have indicated that systolic and possibly pulse pressures are control.39 The recognition of the need for more aggressive BP
more closely correlated with target organ damage than mean control for such patients in the recent guidelines is consistent
arterial or diastolic pressures,1 the pathophysiological basis of with these insights.1,40 Even within the CKD population, the
such empirical observations remains unknown. It is also impact of BP reductions may differ because of intrinsic
possible that the relative pathogenic potential of these indi- differences in susceptibility because of disease cause and
vidual BP parameters may differ for different target organs. severity, as well as genetic and environmental factors.5,7,8 The
Moreover, the transmission of fluctuating systemic pressures steeper the slope of the relationship between BP and renal
to target organs in real time must also be a dynamic process damage, the greater the impact of any given BP reduction.
with the transmission of individual BP fluctuations depending Thus, it is not surprising that greater benefits from aggressive
on their rate (frequency) and the kinetics of the autoregula- BP control are seen in proteinuric than in nonproteinuric
tory responses. And fluctuations in microvascular pressures CKD patients,40 because proteinuria may reflect increased
(pressure transients and/or peak pressures) may have a greater glomerular pressure transmission or may be a biologic marker
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pathogenic potential than sustained steady elevations. The of enhanced intrinsic glomerular susceptibility.
unusually rapid activation kinetics of the afferent arteriolar
myogenic response noted recently seem to be consistent with Class Differences Between Antihypertensives
this protective function.38 Moreover, the fact that systolic, As for experimental models, the relative merits of individual
rather than mean, BP seems to be the trigger signal for this antihypertensive classes and the ability of RAS blockade to
response38 may be indicative of a greater pathogenetic poten- provide BP-independent target organ protection have been
tial of systolic (peak) pressures. Biophysical approaches are the subject of much clinical investigation and debate.1,40 – 44
being developed to separate the BP energy into its component However, the claims for the therapeutic superiority of RAS
parts and to assess the potential renal microvascular trans- blockade have not been sustained, at least for cardiovascular
mission and pathogenic importance of these individual com- disease and stroke, most recently by the very large landmark
ponents of BP power (energy/unit time).5,15,38 ALLHAT trial.1,41– 44 Therefore, recent guidelines now stress
the primary importance of BP reductions per se in preventing
Therapeutic Implications target organ damage.1 In fact, based on their cost and
The pathophysiology of hypertensive renal damage discussed effectiveness in the ALLHAT trial, the thiazide diuretics,
suggests 3 broad targets for therapeutic interventions: (1) despite their expected stimulation of RAS, have been recom-
reduction of BP load; (2) reduction of pressure transmission mended as the initial regimen of choice for most patients with
to the renal microvasculature; and (3) interruption and/or hypertension, with other classes of drugs being added for
modification of the local cellular/molecular pathways that comorbid conditions.1 Patients with CKD, however, remain a
mediate eventual tissue injury and fibrosis. notable exception, with continued emphasis on RAS blockade
as the initial regimen of choice.1,40 These recommendations
Reduction of BP Load are based on the results of several randomized controlled
Given the substantial evidence that local hypertension (baro- clinical trials in diabetic and nondiabetic nephropathy that
trauma) plays a major role in the initiation and progression of have shown better renoprotection with RAS blockade, with
renal damage, it seems self-evident that the most effective 15% to 50% relative risk (RR) reductions in renal disease
preventive strategy would be to treat the proximate cause of endpoints (doubling of serum creatinine, ESRD) in compar-
such increased pressures, ie, effectively reduce the systemic ison to other antihypertensive regimens.1,40,45– 48 Given that
arterial pressures. However, the relative success of such BP the primary importance of optimal BP control is now ac-
reductions in preventing renal damage will vary with the knowledged by even the most avid advocates of RAS
clinical context. Even modest and easily achieved BP reduc- blockade, and that most CKD patients usually require at least
tions to below the autoregulatory threshold are likely to 2 agents for such BP control, the issue of BP-independent
Bidani and Griffin Hypertensive Renal Damage 599
renoprotective superiority of RAS blockade is more of groups. Although such small differences have generally been
scientific than clinical practice relevance because RAS block- felt to be insufficient to explain the 15% to 35% RR
ers are excellent antihypertensive agents when combined with reductions observed in these studies, recent data including
diuretics in this population (vide-infra). that from the ALLHAT study suggest that such small but
Nevertheless, a critical analysis of the clinical trial evi- significant differences in clinic pressures may have greater
dence shows that the interpretations are not as definitive and impact on outcomes than generally assumed.41,43 It is possible
the much emphasized BP-independent benefits of RAS that such differences in clinic BP reflect larger differences in
blockade are much smaller than have been implied. A ambient and/or nocturnal BP, as revealed in a HOPE sub-
re-examination of the landmark clinical trial in type 1 diabetic study.50 Reductions of 3/2 mm Hg in clinic pressures in a
nephropathy patients by the Collaborative Study Group illus- subset of 38 ramipril-treated patients translated into a reduc-
trates this issue.45 A very impressive ⬇50% RR reduction by tion of 10/4 mm Hg in an average 24-hour ambulatory BP
RAS blockade was reported (25 renal end-points in 207 (ABP) in the same patients because of a large decrease in
captopril-treated patients versus 43 in 202 conventionally nocturnal BP of 17/8 mm Hg (ramipril was dosed in the
treated controls), with almost all of the end-points and RR evening). Thus, as in animals, BP-independent effects of RAS
reductions being observed in the higher-risk patients with a blockade are difficult to demonstrate when ABP monitoring
serum creatinine of ⱖ1.5 mg/dL at entry. Although the is used,5,8 suggesting a need for caution when inferring BP
control group had greater proteinuria at entry, and BP during independence based solely on clinic pressures, which are
the course exhibited small but statistically significant differ- usually not controlled for the time of day and/or relationship
ences favoring the captopril group, these large RR reduction to drug dosing. Such effects may be particularly important in
estimates were claimed to not be significantly altered by diabetic hypertensive patients, who often do not exhibit the
statistical adjustment for these differences. However, a sub- normal nocturnal decline in BP.16 Given the experimental
sequently published substudy of the 108 nephrotic patients animal data, it is not surprising that significantly better
considered to be at greatest risk in the original cohort49 casts correlations are observed between 24-hour ABP measure-
considerable doubts on the validity of the interpretations in ments than clinic pressures with markers of cardiovascular
the parent study. Although its implications were not ad- target organ damage, including proteinuria.5,8 Therefore, even
dressed, this substudy revealed that these high-risk nephrotic though intermittent 24-hour ABP monitoring may not provide
patients had been disproportionately randomized, with 42 as complete an assessment of the total chronic BP burden as
being entered in the captopril versus 66 in the placebo group is possible with radiotelemetry in experimental models, its
(P⬍0.002 by 2). The high-risk status of these patients was incorporation in future clinical trials, at least in subsets of
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confirmed by the fact that remission in proteinuria was only patients, should be strongly considered.
achieved in 8 patients (7 in the captopril group) who also Caution also needs to be exercised when drawing conclusions
exhibited very substantial BP reductions, in contrast to the regarding BP-independent effects based on a comparison be-
essentially unchanged BP in the 100 nonresponders whose tween antihypertensive regimens. For instance, there is evidence
average serum creatinine more than doubled during the study. to suggest that -blockers, because of their effects on heart rate
Of note, of the 16 black nephrotic patients, none of whom and the augmentation of the pressure wave reflection, may not
responded, 14 were assigned to the control group (P⬍0.03). lower central pressures as effectively as other agents, despite
It is likely that this flawed randomization of the 24 nephrotic similar peripheral pressure measurements.51 Similarly, the supe-
patients at very high risk to the placebo group largely rior renal outcomes with RAS blockade as compared with CCBs
accounted for the difference of 18 more end-points in the as in the AASK trial,48 might in fact reflect the adverse effects of
control group described in the initial report. CCBs on BP transmission to the microcirculation.20,21 However,
With respect to the relative magnitude of the BP-dependent it should be acknowledged that unlike rodent models, the
versus BP-independent effects of RAS blockade, some in- evidence for deleterious effects of dihydropyridine CCBs in
sights may be provided by the results of the more recent
humans for hard end-points, rather than proteinuria, is more
IDNT and RENAAL trials of angiotensin receptor blockers
mixed.52 This may reflect the limitation of clinic BP measure-
(ARBs) in type 2 diabetic nephropathy.46,47 The additional
ments combined with the fact that the adverse effects of CCBs
renoprotection (slower decline in GFR) provided by ARBs
on renal autoregulation and BP transmission are counteracted by
compared with control antihypertensive regimens was ⬇1
the achieved BP reductions, ie, the greater the BP reduction, the
mL/min per year (⬇5 versus ⬇6 mL/min per year/1.73m2).
less the deleterious impact. Moreover, the deleterious effects of
However, given the GFR decline rates of 12 mL/min per year
CCBs may be significant only in the accelerated GS models in
that have been observed historically in untreated patients,16
which the capillary bed is the primary site of injury and may not
BP reductions per se in the conventionally treated groups
be relevant to more proximal vascular injury. The effectiveness
reduced the rate of GFR decline by 6 mL/min per year.
of CCBs in protecting against malignant nephrosclerosis as well
Therefore, ⬇85% of the total benefit conferred by ARBs may
as cardiovascular and cerebrovascular hypertensive target organ
be attributable to their antihypertensive effects. Moreover, the
damage is consistent with such interpretations.1,41– 43
BP independence of even this residual additional renoprotec-
tion by ARBs may be questioned by the fact that the achieved Achievement of BP Goals
clinic BP in the RAS blockade-treated groups, as in other Over and beyond the issues of the recognition of the need to
clinical trials in diabetic and nondiabetic nephropathy pa- pursue lower BP targets for CKD patients, the difficulty of
tients, tended to be 2 to 4 mm Hg lower than in the control achieving such BP goals has proved to be a major therapeutic
600 Hypertension November 2004
13. Griffin KA, Abu-Amarah I, Picken M, Bidani AK. Renoprotection by ACE 41. The ALLHAT Officers and Coordinators for the ALLHAT Collaborative
inhibition or aldosterone blockade is blood pressure dependent. Hypertens. 2003; Research Group. Major outcomes in high-risk hypertensive patients randomized
41:201–206. to angiotensin-converting enzyme inhibitor or calcium channel blocker vs. diuret-
14. Iversen BM, Sekse I, Ofstad J. Resetting of renal blood flow autoregulation in ic: the antihypertensive and lipid-lowering treatment to prevent heart attach trial
spontaneously hypertensive rats. Am J Physiol. 1987;252:F480–F486. (ALLHAT). JAMA. 2002;2981–2997.
15. Bidani AK, Hacioglu R, Abu-Amarah I, Williamson GA, Loutzenhiser R, Griffin 42. Blood Pressure Lowering Treatment Trialists’ Collaboration. Effects of dif-
KA. “Step” vs. “Dynamic” autoregulation: implications for susceptibility to ferent blood-pressure-lowering regimens on major cardiovascular events:
hypertensive injury. Am J Physiol. 2003;285:F113–F120. results of prospectively-designed overviews of randomized trials. Lancet.
16. Parving H-H, Osterby R, Anderson PW, Hsuch WA. Diabetic Nephropathy. In: 2003;362:1527–1535.
Brenner BM, ed. The Kidney. 5th ed. Philadelphia: WB Saunders Company; 43. Staessen JA, Wang J-G, Birkenhäger WH. Outcomes beyond blood pressure
1996:1864–1892. control? European Heart J. 2003;24:504–514.
17. Griffin KA, Picken M and Bidani AK. Method of renal mass reduction is a critical 44. Jones DW, Hall JE. Seventh report of the Joint National Committee on pre-
determinant of subsequent hypertension and glomerular injury. J Am Soc vention, detection, evaluation and treatment of high blood pressure and evidence
Nephrol. 1994;4:2023–2031. from new hypertension trials. Hypertens. 2004;43:1–3.
18. Christensen PK, Hansen HP. Impaired autoregulation of GFR in hypertensive 45. Lewis EJ, Hunsicker LG, Bain RP, Rohde RD, for the Collaborative Study
non-insulin dependent diabetic patients. Kidney Int. 1997;52:1369–1374. Group. The effects of angiotensin-converting-enzyme inhibition on diabetic ne-
19. Christensen PK, Hommel EE. Impaired autoregulation of the glomerular filtration phropathy. N Engl J Med. 1993;329:1456–1462.
rate in patients with nondiabetic nephropathy. Kidney Int. 1999;56:1517–1523. 46. Lewis EJ, Hunsicker LG, Clarke WR, Berl T, Pohl MA, Lewis JB, Ritz E, Atkins
20. Griffin KA, Picken MM, Bidani AK. Deleterious effects of calcium channel RC, Rohde R, Raz L. Renoprotective effect of the angiotensin receptor antagonist
blockade on pressure transmission and glomerular injury in rat remnant kidneys. irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med.
J Clin Invest. 1995;96:798–800. 2001;345:851–860.
21. Griffin KA, Picken M, Giobbie-Hurder A, Bidani AK. Low protein diet mediated 47. Brenner BM, Cooper ME, de Zeuw D, Keane WF, Mitch WE, Parving HH,
renoprotection in remnant kidneys: renal autoregulatory vs. hypertrophic mech- Remuzzi G, Snapinn SM, Zhang Z, Shahinfar S. Effect of losartan on renal and
anisms. Kidney Int. 2003;63:607–616. cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl
22. Anderson S, Rennke HG, Brenner BM, Zayas MA, Lafferty HM, Troy JL, J Med. 2001;345:861–869.
Sandstrom DJ. Nifedipine versus fosinopril in uninephrectomized diabetic rats. 48. Wright JW, Bakris G, Greene T, Agodoa LY, Appel LJ, Charleston J, Cheek D,
Kidney Int. 1992;41:891–897. Douglas-Baltimore JC, Gassman J, Glassock R, Hebert L, Jamerson K, Lewis J,
23. van Rodijnen WF, van Lambalgen TA, Tangelder GJ, van Dokkum RP, Provoost Phillips RA, Toto RD, Middleton JP, Rostand SG, for the AASK Collaborative
AP, ter Wee PM. Reduced reactivity of renal microvessels to pressure and Research Group. Effect of blood pressure lowering and antihypertensive class on
angiotensin II in fawn-hooded rats. Hypertens. 2002;39:111–115. progression of hypertensive kidney disease: results from the AASK trial. JAMA.
24. Fogo AB. Glomerular hypertension, abnormal glomerular growth, and pro-
2002;288:2421–2431.
gression of renal diseases. Kidney Int. 2000;57:S15–S21.
49. Hebert LA, Bain RP, Verme D, Cattran D, White FC, Tolchin N, Rohde RD,
25. Kriz W, Elger M, Mundel P, Lemley KV. Structure-stabilizing forces in the
Lewis EJ, for the Collaborative Study Group. Remission of nephrotic range
glomerular tuft. J Am Soc Nephrol. 1995;5:1731–1739.
proteinuria in type I diabetes. Kidney Int. 1994;46:1688–1693.
26. Pavenstadt H, Kriz W, Kretzler M. Cell Biology of the glomerular podocyte.
50. Svensson P, de Faire U, Sleight P, Salim Yusuf S, Ostergren J. Comparison of the
Physiol Rev. 2003;83:253–307.
effects of ramipril on ambulatory and office blood pressures. A HOPE substudy.
27. Ketteler M, Noble NA, Border WA. Transforming growth factor and angiotensin
Hypertens. 2001;38:E28–E32.
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