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Effective Antihypertensive Strategies for High-Risk Patients With Diabetic Nephropathy
  1. Peter Noel Van Buren, MD*,
  2. Beverley Adams-Huet, MS,
  3. Robert Daniel Toto, MD*†
  1. From the *Division of Nephrology, Department of Internal Medicine, and †Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX.
  1. Received May 24, 2010, and in revised form September 20, 2010.
  2. Accepted for publication September 20, 2010.
  3. Reprints: Peter Noel Van Buren, MD, University of Texas Southwestern Medical Center Dallas, 5323 Harry Hines Blvd, Dallas, TX 75390-8523. E-mail: vanburenp{at}gmail.com.
  4. Supported by NIH grants from the National Institute of Diabetes, Digestive and Kidney Diseases (2-R01 DK6301001), NCRR General Clinical Research Center grants (M01-RR-00633 and CTSA UL1-RR-024982), K24 (DK00 2818), and CTRC.
  5. The authors have no conflicts of interest to disclose.

Abstract

Aim Clinical guidelines recommend blood pressure (BP) lowering and renin-angiotensin-aldosterone system inhibition to slow kidney disease progression in patients with diabetic nephropathy. This study's purpose was to determine whether an antihypertensive regimen including a maximally dosed angiotensin-converting enzyme inhibitor could safely achieve target BP in indigent, predominantly minority patients with this disease.

Methods We studied 81 hypertensive adults (52% Hispanic and 31% African American) with nephropathy attributed to type 1 or 2 diabetes during the run-in period of a randomized controlled trial. The subjects received lisinopril titrated to 80 mg daily and additional antihypertensives to target a systolic BP (SBP) lower than 130 mm Hg. Blood pressure and serum potassium level were measured weekly, and a 4-gram sodium diet was prescribed. The primary outcome variable was SBP change from screening to randomization. Success in achieving SBP goal, change in urine albumin-creatinine ratio, hyperkalemia (serum potassium ≥5.5 mmol/L) and hypotension (SBP < 100 mm Hg) were also analyzed.

Results The median SBP decreased from 144 to 133 mm Hg (median change, −9.6%.) Fifty-eight (71%) achieved goal SBP during run-in. The median UACR decreased from 206.8 to 112.7 mg/mmol (median change, −42.7%). The UACR reduction correlated with SBP reduction. Seventeen subjects experienced hyperkalemia responsive to dietary/medical management. Two subjects experienced hypotension responsive to medication adjustments.

Conclusion A regimen using a maximally dosed angiotensin-converting enzyme inhibitor is safe and effective for achieving BP goal in high-risk, predominantly minority patients with diabetic nephropathy. Implementing this regimen necessitates close monitoring of serum potassium level.

Key Words
  • albuminuria
  • angiotensin-converting enzyme inhibitor
  • diabetes
  • hypertension
  • nephropathy
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