title: Renal microvascular dysfunction, hypertension and CKD progression.
abstract: OBJECTIVE
  Despite apparent blood pressure (BP) control and renin-angiotensin system (RAS) blockade, the chronic kidney disease (CKD) outcomes have been suboptimal. Accordingly, this review is addressed to renal microvascular and autoregulatory impairments that underlie the enhanced dynamic glomerular BP transmission in CKD progression.
  
  
  RESULTS
  Clinical data suggest that failure to achieve adequate 24-h BP control is likely contributing to the suboptimal outcomes in CKD. Whereas evidence continues to accumulate regarding the importance of preglomerular autoregulatory impairment to the dynamic glomerular BP transmission, emerging data indicate that nitric oxide-mediated efferent vasodilation may play an important role in mitigating the consequences of glomerular hypertension. By contrast, the vasoconstrictor effects of angiotensin II are expected to potentially reduce glomerular barotrauma and possibly enhance ischemic injury. When adequate BP measurement methods are used, the evidence for BP-independent injury initiating mechanisms is considerably weaker and the renoprotection by RAS blockade largely parallels its antihypertensive effectiveness.
  
  
  CONCLUSIONS
  Adequate 24-h BP control presently offers the most feasible intervention for reducing glomerular BP transmission and improving suboptimal outcomes in CKD. Investigations addressed to improving myogenic autoregulation and/or enhancing nitric oxide-mediated efferent dilation in addition to the more downstream mediators may provide additional future therapeutic targets.
authors.affiliation: Loyola University and Hines VA Hospital, Maywood, Illinois 60153, USA. abidani@lumc.edu
authors.forename: Anil K
authors.initials: AK
authors.lastname: Bidani
authors.forename: Aaron J
authors.initials: AJ
authors.lastname: Polichnowski
authors.forename: Rodger
authors.initials: R
authors.lastname: Loutzenhiser
authors.forename: Karen A
authors.initials: KA
authors.lastname: Griffin
mesh_terms: D000804:Angiotensin II / Q000378:metabolism; D001794:Blood Pressure; D018450:Disease Progression; D006706:Homeostasis; D006801:Humans; D006977:Hypertension, Renal / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology*; D007678:Kidney Glomerulus / Q000098:blood supply*; D055806:Microvessels / Q000503:physiopathology*; D009569:Nitric Oxide / Q000378:metabolism; D051436:Renal Insufficiency, Chronic / Q000209:etiology* / Q000378:metabolism
chemical_list: D000804:Angiotensin II; D009569:Nitric Oxide