Nephrosclerosis

Overview – Nephrosclerosis

Nephrosclerosis refers to the scarring and hardening of the nephrons, particularly affecting the renal vasculature. It is a progressive kidney condition often linked to chronic hypertension and diabetes mellitus. Nephrosclerosis is an important pathological cause of chronic kidney disease (CKD), especially in patients with poorly controlled cardiovascular risk factors. This page outlines the definition, pathogenesis, clinical features, diagnosis, and management of nephrosclerosis for final-year medical students.

Definition

• Nephrosclerosis is the stiffening and scarring of renal nephrons, predominantly involving the blood vessels within the kidney.
• It represents a form of chronic vascular kidney damage, most often secondary to long-standing hypertension or diabetes mellitus.

Aetiology

• Hypertension (chronic and poorly controlled)
• Diabetes Mellitus (especially Type 2)

Pathophysiology

• Diabetic Pathway:
  • Chronic hyperglycaemia → blood proteins glycate and become sticky → deposit in small renal vessels.
  • Leads to vessel inflammation, endothelial damage, and progressive scarring.
• Hypertensive Pathway:
  • Elevated blood pressure → mechanical damage to glomerular capillaries.
  • Results in wall thickening, sclerosis, and narrowing of the lumen.
• Common Outcome:
  • Progressive deposition of proteins in the vessel wall → vascular wall thickening.
  • Renal ischaemia → tubular necrosis → loss of nephron function.

Clinical Features

• Often insidious onset — many patients remain asymptomatic for years due to renal reserve.
• Chronic kidney failure symptoms (typically mild, with variable GFR reduction):
  • Anorexia, nausea, vomiting
  • Pruritus
  • Confusion or somnolence
  • Weight loss
• Proteinuria:
  • Common and may reach nephrotic-range levels

Histology

• Large renal arteries:
  • Intimal thickening
  • Medial hypertrophy
  • Duplication of elastic lamina
• Small arterioles:
  • Hyaline arteriolosclerosis (hyaline deposits)
  • Glomerular collapse and sclerosis (“solidified glomeruli”)

Investigations

• Clinical suspicion in the setting of:
  • Longstanding hypertension
  • Diabetes with declining renal function
• Urinary protein/albumin assessment:
  • 24-hour urine collection often shows proteinuria or albuminuria
• Definitive diagnosis:
  • Renal biopsy with histological analysis

Management

• Lifestyle modification:
  • Salt reduction, regular exercise, weight management
• Medical therapy:
  • Tight blood pressure control (target <130/80 mmHg)
  • ACE inhibitors or ARBs (especially in proteinuric patients)
  • Optimal glycaemic control in diabetics

Complications

• Progression to chronic kidney disease or end-stage renal failure
• Increased cardiovascular risk (due to systemic vascular pathology)
• Potential need for dialysis or renal transplant in advanced cases

Differential Diagnosis

• Hypertensive nephropathy
• Diabetic nephropathy
• Chronic glomerulonephritis
• Amyloidosis
• Ischaemic nephropathy

Summary – Nephrosclerosis

Nephrosclerosis is a chronic renal condition marked by scarring and thickening of the renal vasculature, primarily due to long-standing hypertension or diabetes. It may remain clinically silent for years but can eventually result in proteinuria and progressive chronic kidney disease. Diagnosis often hinges on clinical suspicion, proteinuria assessment, and confirmatory histology. Management revolves around tight cardiovascular risk control. For a broader context, see our Renal Overview page.