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      Management of Hypertension in Diabetic Nephropathy: How Low Should We Go?


      Blood Purification

      S. Karger AG

      Nephropathy, Diabetes, Hypertension

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          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.

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          Blood pressure, hypertension, RAAS blockade, and drug therapy in diabetic kidney disease.

          Type 2 diabetes is the most common cause of CKD and ESRD in the United States and the Western world. Hypertension is prevalent in this cohort, and control of blood pressure is perhaps the most important risk factor to reduce CKD progression. The most recent blood pressure target recommended by the Kidney Disease: Improving Global Outcomes and Kidney Disease Outcomes Quality Initiative guideline committees is less than 140/90 mmHg for all patients with CKD. There is some evidence for those with 1 g or more of albuminuria, albeit weak, to support a blood pressure target of less than 130/80 mmHg. Multiple studies demonstrate that renin-angiotensin-aldosterone system (RAAS) blockers are important in reducing cardiovascular risk and progression of CKD in those with advanced proteinuric nephropathy. However, there is no evidence that they prevent nephropathy or that reduction in microalbuminuria alone is associated with slowed nephropathy progression. The purpose of this article is to review the major studies that have evaluated cardiovascular and kidney endpoints in patients with diabetes and the role of RAAS blockers in the treatment of this disease.
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            Prevalence of hypertension in Type 1 (insulin-dependent) diabetes mellitus

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              Early Predictors of 15-Year End-Stage Renal Disease in Hypertensive Patients


                Author and article information

                Blood Purif
                Blood Purification
                Blood Purif
                S. Karger AG (Basel, Switzerland karger@ 123456karger.com http://www.karger.com )
                March 2016
                15 January 2016
                : 41
                : 1-3
                : 139-143
                Department of Medicine, Section of Endocrinology, Diabetes and Metabolism, ASH Comprehensive Hypertension Center, The University of Chicago Medicine, Chicago, IL, USA
                BPU20160411-3139 Blood Purif 2016;41:139-143
                © 2016 S. Karger AG, Basel

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                Page count
                Figures: 2, Tables: 1, References: 22, Pages: 5
                Review - Advances in CKD 2016

                Medicine, General social science

                Hypertension, Diabetes, Nephropathy


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