This article reviews the current state of knowledge concerning the vicious cycle of hypertension and progressive loss of renal function in renal disease, as well as the renoprotective potential of antihypertensive treatment, with a specific focus on children and adolescents. Deficient arteriolar autoregulation renders damaged kidneys particularly sensitive to systemic high blood pressure (BP). Intraglomerular hypertension promotes proteinuria, which further activates the renin-angiotensin system (RAS). Angiotensin II, apart from its vasoconstrictor effects, induces local proinflammatory and profibrotic signaling molecules resulting in renal scarring. The activity of the scarring process with the resultant loss of functional renal mass appears to be modulated, in part, by a polymorphism in the angiotensin converting enzyme (ACE) gene. Clinical studies in adults have demonstrated convincingly the high risk of progression of chronic renal failure (CRF) associated with high BP, the benefit of lowering BP to even the low normal range, and the specific benefit of drugs that inhibit the RAS on the progression of CRF. In children, even moderately elevated BP and moderate proteinuria have been shown to be significant risk factors for progression and CRF. The optimal target BP for children with CRF is currently being determined in a multinational, randomized, prospective tria
