Improvement in treatment of hypertension has not reduced incidence of end-stage renal disease.

Hypertension is an important cause of end-stage renal disease (ESRD) in the USA and in Sub-Saharan Africa. Antihypertensive therapy has led to a substantial decrease in incidence of stroke (42%) and to a lesser extent of myocardial infarction (16%), yet there has been an increase in hypertension related ESRD. In 1991, about 190 000 persons in the USA either underwent dialysis or received a transplant for ESRD. Hypertension was found to be the underlying cause in 29% of these patients, second only to diabetes mellitus (36%). Both in the USA and South Africa hypertension was found to be the most common cause of ESRD, but it is not clear whether this is related to the higher incidence and severity of hypertension in black people. Moreover blood pressure (BP) control in black patients does not necessarily lead to improved renal function. These findings suggest that factors other than BP elevation participate in the progression of nephrosclerosis. They include misdiagnosis, black race (socio-economic status, physiologic differences, severity of hypertension), BP control (adequate control of BP and type of antihypertensive therapy), and possibly other factors like genetics. The lack of reduction in ESRD may be that currently accepted standards for BP control are not adequate and that different antihypertensive agents affect glomerular haemodynamics in different ways. These factors need an in-depth analysis to improve the important public health issue of increasing morbidity and mortality from ESRD.