Optimizing Therapy in the Diabetic Patient with Renal Disease

Abstract

Abstract. Hypertension, impaired renal function, and proteinuria are commonly associated to the presence of diabetes. They play a major role in the development of cardiovascular and renal damage. Effective antihypertensive treatment reduces the progression of diabetic nephropathy and improves cardiovascular prognosis. Accordingly, tight BP control (Ͻ130/80 mmHg) is currently recommended in diabetic patients. Achieving BP targets represents the most important determinant of cardiovascular and renal protection. However, it has been suggested that specific classes of antihypertensive drugs may exert additional organ protection beyond their BP control. The pharmacologic blockade of the renin-angiotensin-aldosterone system has been shown to convey greater renal and cardiovascular protection compared with other classes of drugs. In particular, studies focusing on renal end point suggest that angiotensin-converting enzyme inhibitors (ACEI) are the firstchoice drugs in type 1 diabetes. Both ACEI and angiotensin II receptor blockers prevent the progression from microalbuminuria to clinical proteinuria in type 2 diabetes, but angiotensin blockers provide better renoprotection in patients with overt nephropathy. Regarding cardiovascular protection, several studies (but not all) have shown that ACEI exert a protective effect on diabetic patients. Recently, interesting results in favor of angiotensin receptor blockers have been reported in the IDNT, RENAAL, and LIFE studies. It should be noted that to achieve maximal renal and cardiovascular protection, most diabetic patients require integrated therapeutic intervention, including not only several antihypertensive drugs, but statins and antiplatelet therapy as well.Diabetes, hypertension, impaired renal function, and proteinuria are commonly associated conditions that act as a guilty company. They are, in fact, responsible for an increase in the risk of development and/or progression of cardiovascular disease, nephropathy, and retinopathy.Arterial BP plays a very important role in the development of renal damage and presents a complex relationship with diabetic nephropathy, with nephropathy raising BP, and with BP accelerating the course of nephropathy (1). Furthermore, as shown by epidemiologic studies, hypertension is responsible for increased cardiovascular morbidity and mortality associated with diabetes mellitus (1). Effective antihypertensive treatment reduces the risk of development and progression of nephropathy and, as is especially evident with angiotensinconverting enzyme (ACE) inhibitors (ACEI) and angiotensin receptor blockers (ARB), it lowers cardiovascular morbidity and mortality (2,3). Accordingly, current consensus groups have recommended tight BP control (Ͻ130/80 mmHg) in diabetic patients (2,4 -7).Proteinuria is considered a predictor of renal disease progression. Proteinuria acts on tubular cells by inducing inflammation and consequently interstitial fibrosis. In addition, proteinuria favors dyslipidemia, which aggravates renal damage and increases cardiov...

Effects of Irbesartan on Intracellular Antioxidant Enzyme Expression and Activity in Adolescents and Young Adults With Early Diabetic Angiopathy

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Preventing Renal Complications in Type 2 Diabetes

“…Until DETAIL, only the 1-yr study by Lacourcière et al (16) had compared the effects of an ACE inhibitor versus an ARB. It is known that enalapril has a longterm stabilizing effect on plasma creatinine and proteinuria in normotensive patients with type 2 diabetes (22). Of the available ARB, telmisartan has the highest lipophilicity (23), which assists in tissue penetration; has the longest half-life of approximately 24 h (24); and is almost exclusively excreted in feces (25).…”

Urgent call for reconsideration of chronic kidney disease

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