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Antihypertensive Therapies

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Diabetes and Kidney Disease

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Abstract

Classically, diabetic kidney disease was diagnosed as >300 mg/d of proteinuria in a person with a 10-year history of diabetes mellitus. Kidney biopsy and 24-hour urine collections are now seldom used to monitor such patients, but the lessons of clinical trials performed in the last millennium still hold. Strict glycemic control (e.g., A1c < 7%) has its most impressive impact on preventing diabetic kidney disease in people with type 1 diabetes but continues to be recommended for people with type 2 diabetes. Inhibitors of the renin-angiotensin system prevent both albuminuria and progressive decline in kidney function in people with diabetes, independently of their blood pressure-lowering effects. Before ACE inhibitors, blood pressure-lowering drugs (e.g., diuretics, beta-blockers, and vasodilators) showed similar, albeit probably smaller, beneficial effects on these parameters. Restriction of dietary protein and sodium to reduce albuminuria and/or slow loss of kidney function is often difficult to execute and is less “evidence-based.” Emerging evidence from clinical trials shows that sodium-glucose linked transporter-2 inhibitors can prevent progression of albuminuria and the descent of kidney function to end-stage kidney disease; at least two such agents have received an FDA indication for this. Currently, data are less compelling for glucagon-like peptide-1 agonists, but this may change with ongoing research. Some challenges in this arena include the intrinsic variability of albumin excretion, the many years between the onset of persistent albuminuria and end-stage kidney disease (in the 20–40% of people with type 1 diabetes who develop it), and the competing risk of morbidity and mortality from other causes (especially in people with type 2 diabetes) before end-stage kidney disease.

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  1. Department of Biomedical Sciences, Division of Pharmacology, Pacific Northwest University of Health Sciences, University Parkway, Yakima, WA, USA

    William J. Elliott

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  1. Section of Nephrology, University of Illinois at Chicago/Advocate Christ Medical Center,, Oak Lawn, IL, USA

    Edgar V. Lerma

  2. Nephrology Section, Tulane University, New Orleans, LA, USA

    Vecihi Batuman

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Elliott, W.J. (2022). Antihypertensive Therapies. In: Lerma, E.V., Batuman, V. (eds) Diabetes and Kidney Disease. Springer, Cham. https://doi.org/10.1007/978-3-030-86020-2_23

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  • DOI: https://doi.org/10.1007/978-3-030-86020-2_23

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