CURRENT ISSUES IN TREATING THE HYPERTENSIVE PATIENT WITH DIABETES - FOCUS ON DIABETIC NEPHROPATHY

OBJECTIVE: To review the pathophysiology of hypertension and complicat ions in patients with diabetes mellitus, specifically focusing on diab etic nephropathy; to evaluate the current clinical literature regardin g the appropriate management of hypertension in this patient group; an d to offer treatment recommendations. DATA SOURCES: A MEDLINE search o f applicable English-language clinical studies, abstracts, and review articles pertaining to hypertension, diabetes, and diabetic nephropath y. STUDY SELECTION: Relevant studies on humans, examining hypertension , diabetes, and diabetic nephropathy, and the effects of drug therapy on these interrelated disease states. DATA SYNTHESIS: Pathophysiology of hypertension in the patient with diabetes mellitus and the pathophy siology of diabetic nephropathy are discussed. Studies evaluating the therapeutic effect of certain antihypertensive agents, their effect on glucose control and insulin sensitivity, and the progression of diabe tic nephropathy are reviewed. Recommendations on the treatment of the patient with diabetes and hypertension are given. CONCLUSIONS: The tre atment of the patient with diabetes mellitus and hypertension remains complex. Interventions in this patient population should not only decr ease blood pressure, but also reduce the risk of both vascular and non vascular complications. Data support the theory that by controlling a patient's hypertension, the incidence of albuminuria and the progressi on of diabetic nephropathy are slowed. Additionally, data are availabl e to support the use of pharmacologic interventions in nonhypertensive patients with diabetes and proteinuria. Drug therapies that have prod uced reductions in proteinuria in this patient population include angi otension-converting enzyme inhibitors and nondihydropyridine calcium-c hannel antagonists. Additional information is needed to better differe ntiate the individual agents within each of the antihypertensive drug classes regarding their individual effects on the patient with diabete s and hypertension, specifically effects on diabetic nephropathy and i ts progression to endstage renal disease.