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Evolving therapeutic strategies for retarding progression of diabetic nephropathy--an update for 2002
1Nephrology Section, VA Medical Center, Miami, FL 33125, USA.
Abstract:
During the past few years, several major intervention trials have been conducted in an attempt to determine the efficacy of specific antihypertensive agents in retarding progression of diabetic nephropathy. These studies have clearly demonstrated the importance of renin-angiotensin system blockade in attenuating progressive renal disease. The preferred initial therapy is an angiotensin-converting enzyme (ACE) inhibitor, or an angiotensin type I (AT1) receptor antagonist based on the recent 'landmark' proof-of-concept trials--the Irbesartan Type 2 Diabetic Nephropathy Trial (IDNT) and the Reduction of Endpoints in NIDDM with Angiotensin II Antagonist Losartan (RENAAL). However, these clinical trials also demonstrate that aggressive blood pressure targets are needed in patients with diabetes and hypertension. This frequently requires multiple-drug therapy with several different classes of antihypertensive agents. Data from several clinical trials, including RENAAL, suggest that calcium antagonists may be added to ACE inhibitor or AT1 receptor antagonist therapy as needed to achieve target blood pressure. Calcium antagonists could, therefore, constitute an important component of the antihypertensive regimen in the management of patients with diabetic nephropathy.
Insights
Renin-angiotensin system blockade, using angiotensin-converting enzyme (ACE) inhibitors or angiotensin type I (AT1) receptor antagonists, is key for diabetic nephropathy. Aggressive blood pressure control often requires adding calcium antagonists to dual therapy.
Area of Science:
- Nephrology
- Cardiology
- Endocrinology
Background:
- Diabetic nephropathy is a major complication of diabetes, leading to progressive renal disease.
- Renin-angiotensin system (RAS) blockade has shown efficacy in slowing renal disease progression.
- Landmark trials like IDNT and RENAAL highlight the importance of RAS inhibitors.
Purpose of the Study:
- To review the role of antihypertensive agents in managing diabetic nephropathy.
- To assess the necessity of aggressive blood pressure control in diabetic patients with hypertension.
- To evaluate the potential role of calcium antagonists in combination therapy.
Main Methods:
- Review of major intervention trials on antihypertensive agents in diabetic nephropathy.
- Analysis of data from landmark trials such as IDNT and RENAAL.
- Evaluation of evidence supporting combination antihypertensive therapy.
Main Results:
- RAS blockade with ACE inhibitors or AT1 receptor antagonists is the preferred initial therapy.
- Aggressive blood pressure targets are crucial for patients with diabetes and hypertension.
- Multiple-drug regimens are frequently required to achieve target blood pressure.
- Calcium antagonists may be beneficial as add-on therapy to RAS inhibitors.
Conclusions:
- RAS blockade is fundamental in managing diabetic nephropathy.
- Achieving strict blood pressure control necessitates combination therapy.
- Calcium antagonists represent a valuable option for intensifying antihypertensive treatment in this patient population.