Renal and Cardiovascular Protection in Type 2 Diabetes Mellitus: Angiotensin II Receptor Blockers (original) (raw)
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Background: Inhibition of the renin-angiotensin system in patients with diabetic nephropathy can reduce proteinuria and slow down renal impairment. In this study, we aimed to evaluate the preventive effects of prescribing both angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor inhibitors (ARBs) for renal disease progression compared with administrating each of these two medications alone in patients with type 2 diabetes. Methods: 90 patients with diabetic nephropathy were randomized into three groups: receiving captopril, losartan, and losartan in combination with captopril. Proteinuria was measured before, 2, 6 and 12 months after intervention, and creatinine clearance was measured before and after intervention. Repeated measures ANOVA, Fisher's least significant difference (Fisher's LSD), and t-test were used for data analysis by SPSS software. Findings: Proteinuria was improved in all groups who received medication (P < 0.001). This reduction in the group who received losartan in combined to captopril was more than other groups (P = 0.026). Creatinine clearance was not significantly different between all groups. Conclusion: Administration of ACEI or ARBs reduced proteinuria in patients suffering from diabetic nephropathy (due to type 2 diabetes) but prescribing both drugs had a significantly better outcome. However, creatinine clearance was not significantly improved in any of the groups. Keywords: Diabetes mellitus, Angiotensin-converting enzyme inhibitors, Angiotensin receptor antagonists, Proteinuria
Angiotensin receptor blockers in diabetic nephropathy: renal and cardiovascular end points
Seminars in Nephrology, 2004
The activity of the renin-angiotensin-aldosterone system (RAAS) is elevated both in the circulation and in the renal tissue of diabetic and nondiabetic nephropathies. The increased RAAS activity plays an important role in the hemodynamic and nonhemodynamic pathogenetic mechanisms involved in kidney disease. Previous studies have demonstrated that albuminuria is not only a marker of glomerular lesions, but also a progression promoter, and finally a powerful predictor of the long-term beneficial effect of blood pressure-lowering therapy. Randomized crossover and parallel blind studies in patients with diabetic nephropathy have demonstrated that angiotensin II receptor blockers (ARB) induce favorable changes in systemic blood pressure, renal hemodynamics, and proteinuria similar to those induced by angiotensin-converting enzyme (ACE) inhibition. Studies have revealed the optimal renoprotective dose for some ARBs; however, additional dose titration studies are urgently needed to obtain the maximum benefit of this valuable new class of compounds. The combination of ARB and ACE inhibition is well tolerated and even more effective than monotherapy in reducing systemic blood pressure and albuminuria in diabetic nephropathy. In addition, dual RAAS blockade is safe and well tolerated. Impaired autoregulation of glomerular filtration rate (GFR); demonstrated with some blood pressure-lowering agents implies disturbances in the downstream transmission of the systemic blood pressure into the glomerulus, leading to capillary hypertension or hypotension depending of the level of blood pressure. ARB does not interfere with GFR autoregulation in hypertensive diabetic patients. In contrast to previous observational studies with ACE inhibition, long-term treatment with ARB has similar beneficial renoprotective effect on progression of diabetic kidney disease in hypertensive diabetic patients with ACE II and DD genotypes. ARB can prevent/delay development of diabetic nephropathy independently of its beneficial blood pressure-lowering effect in patients with type 2 diabetes and microalbuminuria. Recently, two landmark studies led to the following conclusion: "Losartan and Irbesartan conferred significant renal benefit in patients with type 2 diabetes and nephropathy. This protection is independent of the reduction in blood pressure it causes. The ARB is generally safe and well tolerated." A recent metaanalysis indicates that ARBs reduce cardiovascular events mainly because of reduction in first hospitalization for congestive heart failure in hypertensive type 2 diabetic patients with albuminuria. The studies mentioned here suggest that ARB represents a beneficial treatment of hypertension and proteinuria in incipient and overt diabetic nephropathy.
Angiotensin-Receptor Blockade versus Converting–Enzyme Inhibition in Type 2 Diabetes and Nephropathy
New England Journal of Medicine, 2005
Few studies have directly compared the renoprotective effects of angiotensin II-receptor blockers and angiotensin-converting-enzyme (ACE) inhibitors in persons with type 2 diabetes. methods In this prospective, multicenter, double-blind, five-year study, we randomly assigned 250 subjects with type 2 diabetes and early nephropathy to receive either the angiotensin II-receptor blocker telmisartan (80 mg daily, in 120 subjects) or the ACE inhibitor enalapril (20 mg daily, in 130 subjects). The primary end point was the change in the glomerular filtration rate (determined by measuring the plasma clearance of iohexol) between the baseline value and the last available value during the five-year treatment period. Secondary end points included the annual changes in the glomerular filtration rate, serum creatinine level, urinary albumin excretion, and blood pressure; the rates of end-stage renal disease and cardiovascular events; and the rate of death from all causes.
Current Hypertension Reports, 2002
It remains unclear how different uses of angiotensin-converting inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) influence the progression of chronic kidney disease (CKD). This study explored CKD progression in a multicentre, longitudinal cohort study that included 2639 patients with CKD stage 1-5 and hypertension. Patients treated with ACEI or ARB for ≥90 days during a 6-mo period comprised the study group, or no treatment, comprised the control group. The study group was subdivided on the basis of treatment: ACEI monotherapy or ARB monotherapy. Progression of renal deterioration was
International Journal of Pharmacy and Pharmaceutical Sciences, 2016
Objective: To observe the clinical outcomes on usage of angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in type 2 diabetic nephropathy patients. Methods: A total 70 patients diagnosed with diabetic nephropathy were treated with ACEIs or ARBs were enrolled in this study. The data was collected from the out patients and the physician. A data collection form was used for collecting patient data. The form was used to record the details of patient's demographics, history of diabetes mellitus, duration of diabetes mellitus co morbidities, food habits and laboratory parameters such as serum creatinine, HbA1c and all the relevant things. The study has obtained ethical clearance from the institution ethics committee (IEC). Results: The study showed middle aged patients were more prone to diabetes and pre-existing hypertension is a major risk factor for diabetic nephropathy. Majority of the patients had long duration of diabetes mellitus which indicates the strong relation between duration of diabetes mellitus with diabetic nephropathy. Compared to ACE inhibitors, ARBs decreased the level of renal parameters. This reveals the better renoprotective effect of ARBs over ACE inhibitors. ARBs had more beneficial effects in reducing the major risk factor like proteinuria in diabetic nephropathy. A considerable reduction in HbA1c values were also observed in patients using ARBs. Conclusion: While comparing the improvement in proteinuria and the laboratory outcomes, ARBs were beneficial relatively to the ACEs in patients with diabetic nephropathy.
Blockade of the renin–angiotensin system for the primary prevention of diabetic nephropathy
Diabetes management, 2012
The prevention of chronic kidney disease is a primary goal for diabetes management. Lowering blood pressure can reduce the incidence of microalbuminuria in Type 1 or Type 2 diabetes, especially in patients with hypertension. Blockade of the renin-angiotensin system (RAS) is an effective strategy to reduce blood pressure in diabetic patients, but no more so than other antihypertensive strategies. RAS blockers have a more favorable side-effects profile compared to other antihypertensive agents, meaning that generally patients are more likely to take them. Any 'independent' effect of RAS blockade for the primary prevention of diabetic nephropathy, beyond blood-pressure control, remains to be clearly established. New combination strategies using renin inhibitors or aldosterone antagonists, to achieve a more complete RAS blockade, have the potential to improve renal outcomes in patients with diabetes. Summary There is clear evidence for the pathogenic role of the renin-angiotensin system (RAS) in the progression of diabetic kidney. Treatment with either an a ngiotensin-converting enzyme inhibitor or angiotensin receptor blocker have been shown to reduce proteinuria and preserve renal function in patients with diabetes and chronic kidney disease. While such data provide a strong rationale for early and sustained blockade of the RAS for the primary prevention of kidney disease, clinical trial evidence to support this goal is limited and inconsistent. By contrast, data from observational and clinical trials clearly demonstrate the primacy of blood-pressure control in the development of diabetic kidney disease, especially in hypertensive patients. Whether RAS blockade offers additional benefits for primary prevention, over-and-above blood-pressure control, remains contentious. At best, any 'independent effects' on primary prevention are modest, and certainly not the panacea envisaged by many practitioners. However, the better tolerability, efficacy and side-effects profile of RAS blockers, and other actions on retinopathy and cardiovascular disease, means that most patients with diabetes currently receive RAS blockers as first line antihypertensive agents. The future development of more effective 'escape-proof' regimens currently offers the best way forward to realize the hope that RAS blockade will ultimately prevent diabetic kidney disease in the clinic as effectively as it does in animal models.
Vascular Health and Risk Management, 2008
Diabetic kidney disease is characterized by persistent albuminuria (Ͼ300 mg/dl or Ͼ200 μg/min) that is confi rmed on at least 2 occasions 3 to 6 months apart, with a progressive decline in the glomerular fi ltration rate (GFR), elevated arterial blood pressure, and an increased risk for cardiovascular morbidity and mortality. Diabetic kidney disease is the leading cause of end stage renal disease (ESRD) prompting investigators to evaluate mechanisms by which to slow disease progression. One such mechanism is to block the activity of angiotensin II at the receptor site and agents that follow this mechanism are referred to as angiotensin receptor blockers (ARB). There is suffi cient clinical evidence to support that ARB have protective effects on kidney function in patients with diabetes and hypertension. However, in the past decade there have been few investigations comparing individual ARBs on renal outcomes. Telmisartan, a lipophilic ARB with a long half-life, has been hypothesized to have a greater anti-proteinuric effect when compared to the shorter acting losartan. Therefore, the A comparison of telMisartan versus losArtan in hypertensive type 2 DiabEtic patients with Overt nephropathy (AMADEO) trial sought to investigate renal and cardiovascular endpoints. In this review, we discuss the pathophysiology of diabetic kidney disease and implications of the AMADEO trial in the context of current understanding from recent outcome trials.
International Journal of Pharmacy and Pharmaceutical Sciences, 2016
Objective : To observe the clinical outcomes on usage of angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in type 2 diabetic nephropathy patients. Methods : A total 70 patients diagnosed with diabetic nephropathy were treated with ACEIs or ARBs were enrolled in this study. The data was collected from the out patients and the physician. A data collection form was used for collecting patient data. The form was used to record the details of patient’s demographics, history of diabetes mellitus, duration of diabetes mellitus co morbidities, food habits and laboratory parameters such as serum creatinine, HbA1c and all the relevant things. The study has obtained ethical clearance from the institution ethics committee (IEC). Results : The study showed middle aged patients were more prone to diabetes and pre-existing hypertension is a major risk factor for diabetic nephropathy. Majority of the patients had long duration of diabetes mellitus which indi...