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Query: UMLS:C0011881 (diabetic nephropathy)
 10,836 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Diabetes mellitus (DM)-linked metabolic alterations and hypertension concomitantly accelerate or precipitate cerebrovascular and coronary heart disease, nephropathy, retinopathy and widespread macroangiopathy, thereby conferring to diabetic patients a very high risk of morbidity, disability and early death. Therefore, the long-term care for diabetic patients should be aimed at concomitant metabolic and blood pressure (BP) control. Dietary measures are indispensable; a high fibre, low fat, low salt diet is recommended, complemented with caloric restriction and physical exercise when body weight is above the ideal. Antidiabetic pharmacotherapy involves an unresolved dilemma. The desired achievement of euglycemia necessitates effective levels of insulin, but hyperinsulinemia (due to parenteral [over]treatment in insulin-dependent DM) is suspected to promote atherogenesis and represents a coronary risk factor and perhaps even facilitates hypertension. Considering antihypertensive pharmacotherapy, thiazide-type or loop diuretics are problematic drugs in DM because they can aggravate metabolic alterations. These agents also seem to exert only a limited preventive or regressive effect on left ventricular hypertrophy (LVH); beta-blockers are also not considered ideal, since they decrease the awareness of hypoglycemia and tend to promote glucose intolerance. Unselective beta-blockers in particular promote peripheral ischemia and insulin-induced hypoglycemia, while beta-blockers without intrinsic sympathomimetic activity lower serum HDL-cholesterol. Calcium antagonists and ACE inhibitors have equivalent antihypertensive efficacy, do not impair carbohydrate and lipid homeostasis or peripheral perfusion and can effectively improve LVH. Certain ACE inhibitors may even slightly ameliorate abnormal insulin sensitivity and plasma glucose levels. While alpha-blockers share most of these desirable properties, these agents are more prone to precipitate orthostatic hypotension in the diabetic patient. The non-thiazide diuretic indapamide and the serotonin2-antagonist ketanserin also combine antihypertensive efficacy with metabolic neutrality. The ultimate goal of therapy is to improve life prognosis. In essential hypertension, conventional drug treatment based on diuretics in high dosage satisfactorily reduced cerebrovascular but not coronary complications or sudden death. In diabetic patients, the influence of antihypertensive therapy on prognosis has not been assessed prospectively. Based on retrospective analyses, Warram et al reported a 3.8 times higher mortality in diabetics treated with diuretics alone, than in diabetics with untreated hypertension (Arch Intern Med. 1991;151:1350). H. H. Parving calculated that effective BP control in patients with diabetic nephropathy might reduce 10 year-mortality from about 65 to 20 percent (J Hypertension. 1990; 8[Suppl 7]:187).(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Antihypertensive therapy in diabetic patients. 128 10

Microalbuminuria is defined as small elevations of urinary albumin excretion not detected by conventional tests. It is associated with elevated arterial pressure, proliferative retinopathy, lipoprotein abnormalities and left ventricular hypertrophy and is predictive of later diabetic nephropathy. Improved glycaemic control and antihypertensive treatment lower urinary albumin excretion but it is not known whether these manoeuvres affect long-term outcome.
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PMID:Implications of microalbuminuria in diabetes. 200 39

The traditional stepped-care approach to antihypertensive therapy, which progresses from simple low-dose monotherapy with diuretics and/or beta-blockers to complex combined regimens, is credited with reduction of hypertension-related stroke morbidity and mortality. However, it has achieved little success in reducing hypertension-related coronary morbidity and mortality. Overall mortality of treated hypertensive patients has remained higher than that of the general population, despite decreases in the blood pressure. In the 1990s, hypertension will be viewed as one of several cardiovascular risk factors requiring individualized treatment that takes concomitant diseases into account. Angiotensin converting enzyme (ACE) inhibitors that do not adversely affect serum lipid and glucose levels will play a major role. This class of drugs will also receive attention because of its beneficial action on diabetic nephropathy and its promising cardioprotective effect achieved by improved coronary blood flow, prevention of left ventricular hypertrophy and prevention of certain potentially life-threatening arrhythmias.
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PMID:The clinical role of angiotensin converting enzyme inhibitors in antihypertensive therapy in the 1990s. 268 6

Echocardiography was used to study the prevalence and severity of left ventricular hypertrophy in patients with established diabetic nephropathy (persistent proteinuria for at least 2 y plus severe retinopathy). Fifteen patients had mild renal impairment (serum creatinine less than 150 mumol l-1), 14 patients had moderate renal impairment (serum creatinine 150-400 mumol l-1), and 20 patients had severe renal impairment (serum creatinine greater than 400 mumol l-1). Thirty-six of the 49 (73%) were on anti-hypertensive treatment, despite which mean blood pressure was 161 +/- 25/89 +/- 9 (+/- SD) mmHg. Left ventricular hypertrophy was demonstrated in 42 of the 49 patients (85%), and increased in severity with increasing renal impairment. Interventricular septal + left ventricular posterior wall thickness was 25 +/- 3 mm in those with mild renal impairment, 28 +/- 6 mm in those with moderate renal impairment and 30 +/- 4 mm in those with severe renal impairment. The most severe left ventricular hypertrophy was seen in the Afro-Caribbean patients. Left ventricular hypertrophy was present even in those with marginally raised blood pressure and was related to age and serum creatinine but not to present blood pressure or duration of proteinuria.
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PMID:Cardiac hypertrophy in diabetic nephropathy: an echocardiographic study. 297 44

The primary aim of the management of hypertension should be to prevent coronary heart disease. Antihypertensive treatment should have a beneficial effect on the risk factors associated with coronary heart disease, particularly hypertension, dyslipidemia, hyperinsulinemia, and/or glucose intolerance. Other important risk factors include central obesity, left ventricular hypertrophy, hypokalemia, and smoking. In patients genetically predisposed to essential hypertension, metabolic alterations characterized by insulin resistance, hyperinsulinemia, and dyslipidemia tend to occur already before the development of hypertension, obesity, or redistribution of body fat. In the treatment of normotensive or borderline hypertensive diabetic patients, angiotensin-converting enzyme (ACE) inhibitors have shown superiority to other agents due to their antiproteinuric effect and their beneficial influence on the glomerular filtration rate. ACE inhibitor treatment of patients with overt diabetic nephropathy has been reported to reduce the risk of mortality and the need for dialysis or transplantation. Beta blockers and thiazide diuretics are still the 'gold standard' of antihypertensive therapy in non-diabetic patients, as they offer at least some prognostic benefit, while the influence of the newer antihypertensive drugs on morbidity and mortality in these patients is not yet known. Nevertheless, since practicing physicians have to treat patients rather than statistical numbers, the current trend towards a more individualized selection, including the newer antihypertensive drugs with consideration of their metabolic, cardiac, and renal action profile, is also difficult to rebut. ACE inhibitors and most calcium antagonists have already evolved as the preferred drugs for the treatment of hypertension in diabetics due to their favorable effects on some of the cardiovascular and renal risk factors.
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PMID:Differential effects of antihypertensive drugs on hypertension: associated risk factors. 774 40

Diabetic nephropathy is the only increasing cause of renal failure in the Western world. It affects a large proportion of both insulin-dependent (IDDM) and non-insulin-dependent diabetic (NIDDM) patients. A critical stage in the development of diabetic renal disease is the onset of microalbuminuria, defined as an albumin excretion rate of 30 to 300 mg/day. Microalbuminuria predicts progression to renal failure and early cardiovascular mortality in both IDDM and NIDDM patients. Microalbuminuria is associated with a constellation of other risk factors for small and large vessel damage which include raised blood pressure, poor glycemic control, plasma lipid and clotting factor abnormalities, left ventricular hypertrophy, and insulin resistance. Treatment with angiotensin-converting enzyme inhibitors corrects microalbuminuria and prevents progression to persistent proteinuria. Good blood glucose control significantly reduces the risk of progression from normoalbuminuria to microalbuminuria. The treatment of microalbuminuria appears highly cost-beneficial and substantially increases life expectancy. The development of microalbuminuria, for which all diabetic patients aged 12 to 70 years should be screened, should alert the physician to set in motion a program of assessment, monitoring, and correction of all risk factors for renal and cardiovascular disease.
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PMID:Prognostic significance of microalbuminuria. 781 38

The objective of this study was to examine diabetic patients at the time of admission to maintenance haemodialysis and to follow them for 36 months in order to define predictors of cardiovascular and non-cardiovascular death. This prospective study comprised all consecutive diabetic patients admitted to 28 German dialysis centres between January 1985 and October 1987; 196 patients were examined, 67 Type 1 (insulin-dependent) diabetic (43 male, 24 female; median age 49 years, range 22-73) and 129 Type 2 (non-insulin-dependent) diabetic patients (54 male, 75 female; 64 years, range 37-82). Outcome measures were death, i.e. myocardial infarction, sudden death, cardiac death of other causes, stroke and non-cardiovascular death. Actuarial survival 36 months after the beginning of dialysis was similar in Type 1 (40%) and Type 2 diabetic patients (43%) despite the age difference. Causes of death were myocardial infarction (18%), sudden death (18%), other cardiac causes (18%); stroke (6%); septicaemia (17%) mostly originating from diabetic foot problems; and interruption of therapy. Survival rates and the proportion dying from cardiac causes were similar in patients with diabetic nephropathy or with other primary chronic renal disease and coincidental diabetes. On dialysis, de novo amaurosis or de novo amputation was not observed in any patient. The strongest predictor of myocardial infarction or sudden death was serum lipids on admission. Duration of hypertension, blood pressure at the time of admission to dialysis, left ventricular hypertrophy or end-diastolic diameter by echocardiography, Sokolow index and average predialysis blood pressure, smoking, interdialytic weight gain and type of dialysis were not predictive of cardiovascular death or death by all causes.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Survival and predictors of death in dialysed diabetic patients. 824 64

The ABCD (Appropriate Blood Pressure Control in Diabetes) Trial is a large, prospective, randomized clinical trial of 950 patients with non-insulin-dependent diabetes mellitus (NIDDM) designed to compare the effects of intensive blood pressure control with moderate control on the prevention and progression of diabetic nephropathy, retinopathy, cardiovascular disease, and neuropathy in NIDDM. The secondary objective is to determine equivalency of the effects of a calcium channel blocker (nisoldipine) and an angiotensin-converting-enzyme inhibitor (enalapril) as a first-line antihypertensive agent in the prevention and/or progression of these diabetic vascular complications. The study consists of two study populations aged 40-74 years, 470 hypertensive patients (diastolic blood pressure of > or = 90.0 mmHg at time of randomization) and 480 normotensive patients (diastolic blood pressure of 80.0 mmHg at time of randomization). The study duration is 5 years and is scheduled to end in May of 1998. Patients are randomized to receive either intensive antihypertensive drug therapy or moderate antihypertensive drug therapy. Patients are also randomized to nisoldipine or enalapril, with open-label medications added if further blood pressure control is necessary. The primary outcome measure is glomerular filtration rate as assessed by 24-h creatinine clearance. Secondary outcome measures are urinary albumin excretion, left ventricular hypertrophy, retinopathy, and neuropathy. Cardiovascular morbidity and mortality will also be evaluated. Given the data showing the impact of hypertension on complications in NIDDM, the ABCD Trial is designed to determine if intensive antihypertensive therapy will be more efficacious than moderate antihypertensive therapy on the outcome of diabetic complications in NIDDM.
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PMID:Appropriate Blood Pressure Control in NIDDM (ABCD) Trial. 896 Aug 57

Hypertension is a common comorbidity with non-insulin-dependent diabetes mellitus (NIDDM). Data are somewhat inconsistent as to whether hypertension exacerbates diabetic complications in this population. Therefore, we examined the relationship between hypertension and vascular complications of NIDDM in the 950 patients enrolled in the prospective and randomized Appropriate Blood Pressure Control in Diabetes (ABCD) study. We found both systolic and diastolic hypertension to be associated with diabetic nephropathy (P < .001) as well as with its macrovascular complications (P < .05). Our present results also demonstrated that there was a significant relationship between hypertension and peripheral vascular disease (P < .05), and left ventricular hypertrophy (P < .001). There was, however, no apparent relationship between hypertension and diabetic neuropathy. Thus, arterial pressure may be a major determinant of complications in NIDDM.
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PMID:Associations of hypertension and complications in non-insulin-dependent diabetes mellitus. 903 22

Kinins are potent bioactive peptides formed by the enzymatic action of kallikrein on kininogens. The discovery that angiotensin-converting enzyme, which generates angiotensin II, is also a major degrading enzyme of kinins, gave rise to the hypothesis that kinin potentiation, in addition to angiotensin II reduction, may be involved in the therapeutic actions of angiotensin-converting enzyme inhibitors. Angiotensin-converting enzyme inhibitors have become important drugs in the treatment of hypertension, congestive heart failure, postmyocardial infarction, and diabetic nephropathy. Although angiotensin II reduction appears to be the predominant mechanism of the antihypertensive effect of chronic angiotensin-converting enzyme inhibitor treatment, the role of kinins in the antihypertensive effects of angiotensin-converting enzyme inhibitors seems to be renin dependent and cannot be generalized for all models of hypertension. On the other hand, at least under experimental conditions, various cardioprotective effects of angiotensin-converting enzyme inhibitors appear to be due to the potentiation of endogenous kinins, including improved cardiac function, structural changes following myocardial ischemia, and induction of capillary growth in hypertension-induced left ventricular hypertrophy.
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PMID:Antihypertensive and cardioprotective effects after angiotensin-converting enzyme inhibition: role of kinins. 922 Mar 13


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