Recent aspects of antihypertensive treatment in patients with diabetic nephropathy

Czech version

Authors: Silvester Krčméry ¹; Ľubomír Polaščín ²; Rastislav Tahotný ¹; Zuzana Gábrišová ¹; Klára Soláriková ¹
Authors‘ workplace: II. klinika geriatrie LFUK UNsP Milosrdní bratia a LF UK v Bratislave ¹; FMC – dialyzačné služby, s. r. o., UN Bratislava – Nemocnica Ružinov ²
Published in: Forum Diab 2012; 1(1): 24-31
Category:

Overview

The occurrence and progression of diabetic nephropathy (DN) is a result of interaction of different metabolic and haemodynamic factors, abnormal stimulation of rennin-angiotensin system (RAS), with the contribution of endothelium dysfunction and reactive oxygen radicals. The increase in intraglomerular pressure is the key haemodynamic abnormality and all therapeutic interventions to decrease intraglomerular hypertension, e.g. RAS inhibitors or low-protein diet, form part of the basic nephroprotective treatment strategy. Microalbuminuria (MAU) is one of the most important parameters in monitoring diabetic patients and is of critical diagnostic, therapeutic and prognostic importance, not only from the nephrological point of view. The main therapeutic interventions include consistent metabolic control of DM and the control of blood pressure. The objective of treatment of manifest diabetic nephropathy is to prevent the progression of diabetic nephropathy to renal failure. Aggressive antihypertensive treatment based on RAS inhibition is the principal objective at this phase.

Kidney Disease Outcome Quality Initiative (K/DOQI) prefers some classes of antihypertensives to prevent the progression of DN. These are primarily ACE-inhibitors (ACEI), angiontensin II AT₁-receptor antagonists (sartans; ARB), aliskiren and non-dihydropyridine calcium channel blockers. There are a number of clinical studies which prove the increased benefit of the above groups of antihypertensives for the reduction of proteinuria and slowing down the progression of nephropathy. Also important from the adverse effect point of view is the fact that the above-mentioned antihypertensives have less adverse metabolic effects than diuretics and betablockers. A number of clinical studies suggest that combined ACEI – sartan therapy can be more effective than monotherapy in the reduction of proteinuria and in slowing down the progression to renal insufficiency. Recent findings suggest that only certain groups of patients with diabetic nephropathy (i.e. those with proteinuria > 1g/24 h, with rapidly progressing decrease of glomerular filtration) are eligible for the treatment using such combination. Among potential risks of the ACEI – sartan combination are primarily the worsening of renal anaemia and hyperkaliemia. Aliskiren is the first representative of the new class of antihypertensives with a unique mechanism of action – direct rennin inhibition. Its antihypertensive effect has been proven in both monotherapy and combined treatment of hypertension in nephropathy patients.

Key words:
diabetic nephropathy – ACE-inhibitors – sartans – aliskiren

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Labels

Diabetology Endocrinology Internal medicine

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Diabetic retinopathy 1

DPP-4-inhibitors – What are the similarities, where are the differences?

Article was published in

Forum Diabetologicum

2012 Issue 1