Treating Hypertension in Diabetic Nephropathy

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Treating Hypertension in Diabetic Nephropathy
Received for publication 25 September 2002 and accepted in revised form 22 February 2003
Jeremy W. Tomlinson, MRCP, Katharine R. Owen, MRCP and Colin F. Close, MD
Diabetes Care
© 2003 by the American Diabetes Association, Inc.

Epidemiology/Health Services/Psychosocial Research
Original Article

From the Department of Diabetes, Taunton and Somerset Hospital, Taunton, U.K.

ABSTRACT

OBJECTIVE—Control of hypertension in patients with diabetic nephropathy improves mortality and slows progression to end-stage renal disease. However, blood pressure is difficult to treat; multiple drug combination therapy is required and treatment algorithms to establish this are lacking. We used a stepped-care algorithm, centered on maximum doses of an ACE inhibitor or angiotensin II receptor blocker, to treat hypertension according to American Diabetes Association recommended blood pressure target goals (<130/80 mmHg) in patients with diabetic nephropathy.

RESEARCH DESIGN AND METHODS—We treated 49 consecutive patients with diabetes (13 with type 1 and 36 with type 2), diabetic nephropathy, and proteinuria >=500 mg/24 h with a stepped-care blood pressure treatment algorithm. The level of blood pressure control achieved at most recent follow-up was assessed.

RESULTS—Patients were followed for a median of 18 months (range 9–48). Mean blood pressure achieved was 140/75 ± 23/14 mmHg in patients with type 1 diabetes and 146/76 ± 22/14 mmHg in patients with type 2 diabetes. Target blood pressure was reached in 16 (33%) patients, 6 of 13 patients with type 1 diabetes and 10 of 36 patients with type 2 diabetes, whereas systolic blood pressure remained above the target level in the remaining patients. There was no difference in baseline blood pressure, proteinuria, or serum creatinine level between patients who were treated to target and those who were not.

CONCLUSIONS—Levels of blood pressure control similar to those achieved in clinical trials in diabetic nephropathy were obtained with a stepped-care algorithm. However, in most patients, systolic blood pressure was difficult to control to target despite the use of multiple drug combination therapy.

Abbreviations: ARB, angiotensin II receptor blocker

INTRODUCTION

Hypertension is a major risk factor for cardiovascular morbidity and mortality in patients with diabetes (1,2). Diabetic nephropathy develops in up to 40% of patients with type 1 diabetes (3) and 35% of patients with type 2 diabetes (4), and rigorous treatment of hypertension slows the rate of decrease in renal function and improves mortality (5,6). Few studies have addressed whether recommended targets for blood pressure control (7,8) can be achieved in everyday clinical practice, and although multiple drug combination therapy is needed to treat hypertension in most patients with nephropathy, treatment algorithms for establishing this are lacking and the optimum drug combination remains uncertain. After review of the evidence available in 1998 (7,9–18), we devised a stepped-care algorithm for treating hypertension in diabetic nephropathy and evaluated its ability to treat hypertension to American Diabetes Association recommended blood pressure target goals (8) in consecutive patients with diabetic nephropathy attending a hospital diabetes clinic.

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