OBJECTIVE -To compare the effectiveness of a nurse-led hypertension clinic with conventional community care in general practice in the management of uncontrolled hypertension in patients with type 2 diabetes.RESEARCH DESIGN AND METHODS -We studied 120 men and women outpatient attendees (61% non-Caucasian) with type 2 diabetes and a seated blood pressure (BP) Ն140/80 mmHg. All patients were being treated for hypertension, and 71% had increased urinary albumin excretion (UAE). Patients were allocated to either a nurse-led hypertension clinic or conventional primary care. The primary outcome measure was a change in systolic BP. Secondary outcome measures were total cholesterol, HDL cholesterol, total triglycerides, HbA 1c , UAE, serum creatinine, and changes in absolute stroke and coronary heart disease (CHD) risk scores.RESULTS -The mean (95% CI) difference in the decrement of systolic BP was 12.6 mmHg (5.9 -19.3) (P ϭ 0.000) in favor of the nurse-led group, whose patients were three times more likely to a reach target systolic BP Ͻ140 mmHg compared with conventional care (P ϭ 0.003). A significant fall in 10-year CHD (P ϭ 0.004) and stroke risk (P ϭ 0.000) scores occurred only in the nurse-led group. There were no significant differences in the reduction of diastolic BP or any of the other secondary outcome measures at 6 months.CONCLUSIONS -Compared with conventional care, a nurse-led hypertension clinic is a more effective intervention for patients with type 2 diabetes and uncontrolled hypertension. A target systolic BP Ͻ140 mmHg is more readily achieved and may be associated with significant reductions in 10-year cardiovascular disease risk scores. Diabetes Care 26:2256 -2260, 2003H ypertension is a major and modifiable risk factor for cardiovascular disease that frequently coexists with diabetes (1). A progressive rise in blood pressure (BP) is also a promoter of renal dysfunction and the development of end-stage renal failure (2). The presence of proteinuria and hypertension also increases the risk of premature death from cardiovascular disease eightfold compared with unaffected patients (3,4). A large evidence base of randomized controlled trials have demonstrated that treating hypertension reduces morbidity and mortality from hypertension-related diseases (5,6). More recently, the use of antihypertensive agents that interrupt the renin-angiotensin system has been shown to be an effective strategy to retard the progression of nephropathy and reduce cardiovascular events in people with diabetes (7-9). Throughout the western world, expert committees on hypertension recommend that treatment to lower BP is warranted in patients with diabetes who have a systolic BP Ն140 mmHg (10,11). Currently, hypertension is poorly managed. The Health of England Survey (12) suggests that Ͻ30% of affected patients receiving treatment have attained target BP. Furthermore, it has been suggested that with current models of care, the attainment of these stringent BP targets for patients with diabetes may not be attainable in the maj...

Abstract. Diabetic nephropathy is a leading cause of end-stage renal failure. Its incidence is higher and is increasing in persons of Indo-Asian and African-Caribbean (African-Asian) compared with those of white origin. Nitric oxide deficiency is associated with progressive renal disease. It was hypothesized that differences in the capacity to increase glomerular filtration (functional renal reserve) would exist between these racial groups in relation to nitric oxide availability. Patients with type 2 diabetes of African-Asian (n = 9) and white (n = 9) origin with microalbuminuria were studied under euglycemic conditions. Glomerular filtration, renal plasma flow, and clearance of the stable metabolites of nitric oxide, nitrite, and nitrate were measured before and after a renal vasodilatory stimulus of a mixed amino acid intravenous infusion. There were no significant differences in age, duration of diabetes, and baseline glomerular filtration (57.1 [14.1] versus 55.8 [10.1] yr; P = 0.82, 14.5 [10.2] versus 9.1 [7.0] yr; P = 0.19 and 125.9 [30.9] versus 127.2 [44.6] ml/min per 1.73 m2; P = 0.94) between the African-Asian and white groups. Functional renal reserve, change in renal plasma flow, and percentage change in nitrate and nitrite clearance was significantly higher in the white compared with the African-Asian group (21.9 [45.7] versus -2.5 [28.2] ml/min per 1.73 m2; P = 0.043, 155.8 [205.9] versus -90.1 [146.0]; P = 0.03 ml/min per 1.73m2 and 26.7 [85.1] versus -44.7 [16.9] %; P = 0.013, respectively). The differences in functional reserve were not confounded after adjustment for diabetes duration (P = 0.034). The data suggest that these patients with type 2 diabetes of African and Asian origin lose functional renal reserve earlier in the evolution of nephropathy than whites. The differences appear to be due to defective nitric oxide production or bioavailability and might explain some of the propensity to develop end-stage renal disease.

A population-based cross-sectional survey was carried out to study potential environmental risk factors contributing to diabetes and cardiovascular risk in the same homogeneous group in the United Kingdom and in Dar es Salaam, Tanzania. In Dar es Salaam, 222 members of the Bhatia community aged 15 years and over were studied. In the UK, 180 randomly selected subjects aged 15 years and over participated. Age, sex, and body mass index adjusted mean levels of fasting glucose (5.5 mmol l-1 vs 5.1 mmol l-1 (p < 0.001)) and 2 h glucose (6.8 mmol l-1 vs 6.0 mmol l-1 (p < 0.001)) were significantly higher in Tanzanian subjects than in UK subjects. Mean levels of serum triglycerides (1.5 mmol l-1 vs. 1.3 mmol l-1 (p < 0.05)) and systolic blood pressure (135 mmHg vs 127 mmHG (p < 0.05) were significantly higher in subjects in the UK. The age and sex adjusted prevalence of impaired glucose tolerance (28.4% vs 11.4% (p < 0.001)), newly diagnosed diabetes (8.6 % vs 1.5% (p < 0.01)), hypercholesterolaemia (9.9% vs 1.5% (p < 0.001)), and smoking (12.1% vs 3.9% (p < 0.01)) were significantly higher in subjects in Tanzania compared to subjects in the UK. The prevalence of known diabetes, hypertriglyceridaemia, hypertension, and obesity did not show significant differences between subjects in Tanzania and those in the UK. Within the same homogeneous community with the same likely genetic predisposition, there are substantial geographical differences in cardiovascular risk factors, the causes of which remain to be determined.