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Diabetes and chronic kidney disease: tragedy and challenge
1Department of Preventive Medicine, Rush University Hypertension/Clinical Research Center, Rush Presbyterian/St. Luke's Medical Center, Chicago, IL 60612, USA.
Insights
Managing hypertension in diabetic nephropathy requires multiple medications to reach blood pressure goals. Despite recommendations, few patients achieve target blood pressure, highlighting a gap in cardiovascular risk reduction for diabetics.
Area of Science:
- Nephrology
- Cardiology
- Endocrinology
Background:
- Hypertension management in diabetic nephropathy is complex, often needing multiple antihypertensive agents.
- Current recommended blood pressure (BP) goal is <130/80 mm Hg to reduce cardiovascular (CV) risk and preserve kidney function.
- Commonly used combinations include ACE inhibitors or ARBs with diuretics, potentially adding beta-blockers or calcium antagonists.
Purpose of the Study:
- To highlight the challenges in achieving target BP in patients with diabetic nephropathy.
- To emphasize the importance of comprehensive cardiovascular risk reduction strategies in diabetes management.
Main Methods:
- Analysis of the NHANES III database to assess BP control in diabetic kidney disease.
- Review of recent data from Denmark on total CV risk reduction strategies in diabetes.
Main Results:
- Only about 11% of individuals with diabetic kidney disease achieved the target BP of <130/80 mm Hg.
- Intensive CV risk reduction, including BP and lipid goals, aspirin, exercise, and diet, reduced absolute CV event risk by 20% compared to less intensive treatment.
Conclusions:
- Achieving target blood pressure in diabetic nephropathy remains a significant clinical challenge.
- A holistic approach to cardiovascular risk management is crucial for patients with diabetes.
Abstract:
Management of hypertension in diabetic nephropathy is challenging and generally requires a minimum of three different and complementary antihypertensive agents to achieve the recently recommended blood pressure (BP) goal of <130/80 mm Hg in order to reduce cardiovascular (CV) risk and preserve kidney function. Commonly used antihypertensive combinations include an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker, agents that have compelling indications for use in diabetic renal disease, added to a diuretic, generally a thiazide-type agent. If additional therapy is required, either a beta-blocker or calcium antagonist may be added. Beta-blockers are particularly effective in people with a high sympathetic drive, i.e. high pulse rates, to lower BP and reduce CV risk while reducing proteinuria and slowing decline of kidney function. In light of this information, it is disturbing that a recent analysis of the NHANES III database indicates that only about 11% of people with diabetic kidney disease have achieved the target BP of <130/80 mm Hg. Recent data from Denmark demonstrate that focusing on total CV risk reduction among people with diabetes, including achievement of recommended BP and lipid goals along with the use of aspirin, exercise and a proper diet, can reduce the absolute risk of a CV event by 20% over less intensive treatment.