This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Saved Citations Download to citation manager Request Permissions Request Reprints Add to My Marked Citations Citing Articles Citing Articles via Google Scholar Citing Articles via Scopus Google Scholar Articles by Walker, J. D Search for Related Content Social Bookmarking                         What's this?

Commentary: Should BP targets be lower in diabetic patients with microalbuminuria or nephropathy?

Medical Unit, St Johns Hospital, Livingston, EH54 6PP, UK, james.walker{at}wlt.scot.nhs.uk

The authors in the preceding paper have answered a number of specific questions regarding the management of diabetic renal disease. Using a systematic review, they have concluded that although urinary albumin excretion decreases in patients randomised to lower blood pressure (BP) levels within the normotensive range (< 140/90 mmHg), no trials to-date have demonstrated a beneficial effect on glomerular filtration rate (GFR). Thus, the authors state that the available literature does not provide dat S a to support the assertion that BP-lowering within the normotensive range reduces the risk of renal replacement therapy. However, these findings require interpretation before they can influence clinical practice. The benefits of BP-lowering extend far beyond the glomerulus — a fact of crucial importance in terms of the macrovasculopathy so frequently seen inpatients with diabetic renal disease. Moreover, achieving BP levels within the normotensive range in these patients is in itself a success. The analysis provided by Kaiser et al. does suggest that, rather than lowering BP within the normotensive range, other therapeutic avenues may be more fruitfully explored to maximise health gain in this high-risk cohort.

References

• Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study. BMJ 1998;317:703-13.[Abstract/Free Full Text]
• Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Heart Outcomes Prevention Evaluation Study Investigators. Lancet 2000;355:253-9.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Kasiske BL, Kalil RSN, Ma JZ, Liao M., Keane WF Effect of antihypertensive therapy on the kidney in patients with diabetes: a meta-regression analysis. Ann Intern Med 1993;118:129-38.[Abstract/Free Full Text]
• The ACE Inhibitors in Diabetic Nephropathy Trials Group. Should all patients with type 1 diabetes and microalbuminuria receive angiotensin-converting enzyme inhibitors? A meta-analysis of individual patient data. Ann Intern Med 2001;134:370-9.[Abstract/Free Full Text]
• Kshirsagar AV, Joy MS, Hogan SL, Falk RJ, Colindres RE Effect of ACE inhibitors in diabetic and non-diabetic chronic renal disease: a systematic overview of randomised placebo-controlled trials. Am J Kid Dis 2000;35:695-707.[Web of Science][Medline] [Order article via Infotrieve]
• Mann JFE, Gerstein HC, Pogue J., Bosch J., Yusef S. for the HOPE investigators.Renal insufficiency as a predictor of cardiovascular outcomes and the impact of ramipril: the HOPE randomised trial. Ann Intern Med 2001;134:629-36.[Abstract/Free Full Text]
• Parving HH, Lehnert H., Brochner-Mortensen J., Gomis R., AndersenS, Arner P. The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. N Engl J Med 2001;345: 870-8.[Abstract/Free Full Text]
• Lewis EJ, Hunsicker LG, Bain RP, Rohde RD The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. The Collaborative Study Group. N Engl J Med 1993;329:1456-62.[Abstract/Free Full Text]
• Lewis EJ, Hunsicker LG, Clarke WR et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med 2001;345:851-60.[Abstract/Free Full Text]
• Brenner BM, Cooper ME, De Zeeuw D. et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 2001;345:861-9.[Abstract/Free Full Text]
• Messent JW, Elliott TG, Hill RD, Jarrett RJ, Keen H., Viberti GC Prognostic significance of microalbuminuria in insulin-dependent diabetes mellitus: a twenty-three year follow-up study. Kidney Int 1992;41: 836-9.[Web of Science][Medline] [Order article via Infotrieve]
• Hovind P., Rossing P., Tarnow L., Smidt UM, Parving HH Progression of diabetic nephropathy. Kidney Int 2001;59:702-09.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Wang SL, Head J., Stevens L., Fuller JH Excess mortality and its relation to hypertension and proteinuria in diabetic patients. The world health organization multinational study of vascular disease in diabetes. Diabetes Care 1996;19:305-12.[Abstract]
• Mogensen CE Microalbuminuria predicts clinical proteinuria and early mortality in maturity-onset diabetes. N Engl J Med 1984;310:356-60.[Abstract]
• Mattock MB, Morrish NJ, Viberti G., Keen H., Fitzgerald AP, Jackson G. Prospective study of microalbuminuria as a predictor of mortality in NIDDM. Diabetes 1992;41:736-41.[Abstract]
• Schmitz A., Vaeth M. Microalbuminuria: a major risk factor in non-insulin dependent diabetes. A 10-year follow-up study of 503 patients. Diabet Med 1988;5:126-34.[Web of Science][Medline] [Order article via Infotrieve]
• Ruggenenti P., Schieppati A., Remuzzi G. Progression, remission, regression of chronic renal diseases. Lancet 2001;357:1601-08.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Bilous RW Baseline and changes in proteinuria and the risk of renal functional loss in the Irbesatan Diabetic Nephropathy Trial (IDNT). Diabetic Med 2003;20(Suppl 2):A68.
• Estacio RO, Jeffers BW, Gifford N., Schrier RW Effect of blood pressure control on diabetic microvascular complications in patients with hypertension and type 2 diabetes. Diabetes Care 2000;23(Suppl 2):B54-B64.[Web of Science][Medline] [Order article via Infotrieve]
• Schrier RW, Estacio RO, Esler A., Mehler P. Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and strokes. Kidney Int 2002;61:1086-97.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Lewis JB, Berl T., Bain RP, Rohde E RP, Lewis EJ Effect of intensive blood pressure control on the course of type 1 diabetic nephropathy. Am J Kidney Dis 1999;34:809-17.[Web of Science][Medline] [Order article via Infotrieve]
• Tindall H., Bilous RW The effect of achieved blood pressure levels on renal outcomes in the Irbesatan Diabetic Nephropathy Trial (IDNT). Diabetic Med 2003;20(suppl 2):A67.
• Adler AI, Stratton IM, Neil AW et al. on behalf of the UKPDS Group. Association of systolic blood pressure with macrovascular and microvascular complications in type 2 diabetes (UKPDS 36): prospective observational study. BMJ 2000;321:412-19.[Abstract/Free Full Text]
• Hansson L., Zanchetti A., Carruthers SG et al. Effect of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the hypertension optimal treatment (HOT) randomised trial. Lancet 1998;351:1755-62.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• National Institute for Clinical Excellence. Management of Type 2 diabetes. Renal disease - prevention and early management. Inherited Clinical Guideline F. February 2002. www.nice.org.uk
• Gaede P., Vedel P., Larsen N., Jensen GVH, Parving H-H., Pedersen O. Multifactorial intervention and cardiovascular disease in patients with Type 2 diabetes. N Engl J Med 2003;348:383-93.[Abstract/Free Full Text]

The British Journal of Diabetes & Vascular Disease, Vol. 3, No. 4, 282-284 (2003)
DOI: 10.1177/14746514030030040901


CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter    What's this?

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Saved Citations Download to citation manager Request Permissions Request Reprints Add to My Marked Citations Citing Articles Citing Articles via Google Scholar Citing Articles via Scopus Google Scholar Articles by Walker, J. D Search for Related Content Social Bookmarking                         What's this?