Antihypertensive agents in patients with diabetes: trade-off between renal and cardiovascular protection.
Management of hypertension in patients with diabetes should address both renal and cardiovascular protection. The use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) for control of hypertension in patients with diabetic nephropathy is widely advocated by various international guidelines. Use of any agent that provides tight control of blood pressure is indicated in patients with diabetes but without nephropathy.



In this article, the authors present a clinical case scenario and review current clinical evidence supporting the use of ACE inhibitors and ARBs in patients with diabetic nephropathy. In addition, the use of ACE and ARBs in patients with diabetes but without nephropathy will be discussed.



Available trial evidence confirms the survival benefits of patients taking ACE inhibitors with diabetic nephropathy. However, the efficacy of ARB inhibitors on survival is unknown. In patients with diabetes without nephropathy, only ACE inhibitors have been found to reduce the risk of onset of microalbuminuria, while all agents affect survival provided a tight control of blood pressure is monitored.



Dose of ACE inhibitors should be titrated appropriately to obtain proven benefits. In summary, current evidence supports the use of ACE inhibitors in patients with and without nephropathy because of renal and cardiovascular benefits.
Navaneethan
Sankar D
SD
The Division of Nephrology, University of Rochester, Rochester, New York (Dr Navaneethan)
Querques
Marialuisa
M
University of Milan San Raffaele, Milan, Italy (Dr Querues)
Bonifati
Carmen
C
Department of Emergency and Organ Transplantation, University of Bari, Italy (Dr Bonifati)
Strippoli
Giovanni F M
GF
The Centre for Kidney Research, Cochrane Renal Group, University of Sydney, Australia (Dr Strippoli)
D000419:Albuminuria; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D002318:Cardiovascular Diseases / Q000517:prevention & control*; D003924:Diabetes Mellitus, Type 2 / Q000150:complications / Q000503:physiopathology*; D003925:Diabetic Angiopathies / Q000517:prevention & control; D003928:Diabetic Nephropathies / Q000517:prevention & control; D006801:Humans; D007674:Kidney Diseases / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D012016:Reference Values
D000959:Antihypertensive Agents