title: Management of Hypertension in Diabetic Nephropathy: How Low Should We Go?
abstract: Hypertension is a frequent comorbidity often following the development of diabetic nephropathy among individuals with type 1 diabetes and affecting most patients with type 2 diabetes at the time of diagnosis. Multiple prospective randomized placebo-controlled trials demonstrate that tight blood pressure control among patients with diabetic nephropathy reduces the rates of macrovascular and microvascular complications. While randomized trials exist and support a blood pressure goal of <140/90 mm Hg for patients with nondiabetic kidney disease, there are no prospective data regarding a specific blood pressure goal on progression of diabetic nephropathy. Retrospective data analyses from trials show a linear relationship between either baseline or achieved study blood pressure and progression of nephropathy. Very high albuminuria is a hallmark of diabetic nephropathy with reductions by either angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor blocker (ARB) monotherapy associated with slowed nephropathy progression. However, combination antihypertensive therapy, while decreasing proteinuria, augments the risk of hyperkalemia, hypotension, and kidney dysfunction. Given the lack of trial data for a BP goal among patients with diabetic nephropathy, prospective trials are needed to define the optimal blood pressure necessary to preserve kidney function. At present, guideline blood pressure goals of less than 140/90 mm Hg and the use of ACEi or ARB therapy for those with more than 300 mg of albuminuria are mandated.
authors.affiliation: Department of Medicine, Section of Endocrinology, Diabetes and Metabolism, ASH Comprehensive Hypertension Center, The University of Chicago Medicine, Chicago, IL, USA.
authors.forename: Hillel
authors.initials: H
authors.lastname: Sternlicht
authors.forename: George L
authors.initials: GL
authors.lastname: Bakris
mesh_terms: D000419:Albuminuria / Q000188:drug therapy / Q000453:epidemiology* / Q000503:physiopathology; D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D001794:Blood Pressure / Q000187:drug effects; D015897:Comorbidity; D003922:Diabetes Mellitus, Type 1 / Q000188:drug therapy / Q000453:epidemiology* / Q000503:physiopathology; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy / Q000453:epidemiology* / Q000503:physiopathology; D003928:Diabetic Nephropathies / Q000188:drug therapy / Q000453:epidemiology* / Q000503:physiopathology; D019468:Disease Management; D006801:Humans; D006973:Hypertension / Q000188:drug therapy / Q000453:epidemiology* / Q000503:physiopathology; D017410:Practice Guidelines as Topic; D016032:Randomized Controlled Trials as Topic
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors