Long-term renal outcomes of patients with biopsy-proven malignant hypertension-associated renal thrombotic microangiopathy who are dialysis-independent at baseline

This observational cohort study aimed to identify factors influencing long-term renal outcomes in 170 patients with biopsy-proven malignant hypertension (MHT)–associated renal thrombotic microangiopathy (TMA) who were dialysis-independent at baseline, recruited between 2008 and 2023. Over a median follow-up of 23.5 months, 52 patients (30.6%) progressed to end-stage renal disease (ESRD). Those developing ESRD exhibited significantly higher total cholesterol levels, heavier proteinuria, a greater proportion of global glomerulosclerosis, more advanced interstitial fibrosis/tubular atrophy, and lower baseline eGFR, along with lower use of renin-angiotensin-aldosterone system (RAAS) inhibitors. In Cox regression analysis, elevated total cholesterol (HR = 1.48 per 1 mmol/L change; 95% CI: 1.24–1.77, p < 0.001) and a higher percentage of glomerulosclerosis (HR = 1.24, 95% CI: 1.15–1.33, p < 0.001; per 5% increase of glomerulosclerosis) were independent risk factors for ESRD, while RAAS inhibitor use was associated with a significantly reduced risk (HR = 0.45, 95% CI: 0.25–0.82, p = 0.009). These findings underscore the prognostic value of lipid profiles and histologic injury severity in MHT-associated TMA and support the protective role of RAAS blockade in preserving renal function, which may guide risk stratification and therapeutic decisions in this high-risk population.