Management of hypertension and renin-angiotensin-aldosterone system blockade in adults with diabetic kidney disease: Association of British Clinical Diabetologists and the Renal Association UK guideline update 2021

Abstract

People with type 1 and type 2 diabetes are at risk of developing progressive chronic kidney disease (CKD) and end-stage kidney failure. Hypertension is a major, reversible risk factor in people with diabetes for development of albuminuria, impaired kidney function, end-stage kidney disease and cardiovascular disease. Blood pressure control has been shown to be beneficial in people with diabetes in slowing progression of kidney disease and reducing cardiovascular events. However, randomised controlled trial evidence differs in type 1 and type 2 diabetes and different stages of CKD in terms of target blood pressure. Activation of the renin-angiotensin-aldosterone system (RAAS) is an important mechanism for the development and progression of CKD and cardiovascular disease. Randomised trials demonstrate that RAAS blockade is effective in preventing/ slowing progression of CKD and reducing cardiovascular events in people with type 1 and type 2 diabetes, albeit differently according to the stage of CKD. Emerging therapy with sodium glucose cotransporter-2 (SGLT-2) inhibitors, non-steroidal selective mineralocorticoid antagonists and endothelin-A receptor antagonists have been shown in randomised trials to lower blood pressure and further reduce the risk of progression of CKD and cardiovascular disease in people with type 2 diabetes. This guideline reviews the current evidence and makes recommendations about blood pressure control and the use of RAAS-blocking agents in different stages of CKD in people with both type 1 and type 2 diabetes.

Hypertension attenuates the link of osteoprotegerin to reduced baroreflex sensitivity in type 2 diabetes mellitus patients on oral antidiabetic and antihypertensive therapy – a cross sectional study

“…Persistent low-grade inflammation and oxidative stress in the adipose tissue results in increased production of angiotensinogen and angiotensin II that leads to the elevation in BP [ 52 , 53 ]. Therefore, ACE inhibitors are usually preferred antihypertensive drugs in diabetes with hypertension [ 11 ]. Increased adipose tissue mass (obesity) and increased visceral adiposity are the key factors behind the coexistence of both diabetes and hypertension [ 2 ], and obesity is known to influence HRV and BRS [ 54 ].…”

“…Metformin inhibits sympathetic activity by acting centrally on hypothalamic nuclei [ 7 , 9 , 10 ] and glimepiride promotes vagal tone, possibly stimulating the medullary cardioinhibitory center [ 8 ]. For the treatment of hypertension in diabetes, calcium channel blockers or angiotensin-converting enzyme (ACE) inhibitors are frequently prescribed as a single drug or in combination [ 11 ]. In our setup, amlodipine and enalapril are commonly used to manage hypertension in diabetes.…”

Efficacy and safety of Keluoxin capsule in combination with Western medicine for diabetic kidney disease: A systematic review and meta-analysis

“…Improving albuminuria and reducing eGFR in DKD patients are important treatments to delay the progress to ESRD ( Banerjee et al, 2021 ). Current therapies to postpone the progression of CKD include angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), and sodium–glucose cotransporter 2 (SGLT2) inhibitors ( Barrera-Chimal et al, 2021 ; Wang et al, 2021 ; Ravindran and Munusamy, 2022 ).…”

Network-based identification and prioritization of key transcriptional factors of diabetic kidney disease

“…It is majorly the glomerular damage, besides tubulointerstitial fibrosis, contributing to the pathogenesis of DN [6] , [7] . The current treatment for DN is controlling glucose levels and reducing systemic blood pressure using renin-angiotensin system inhibitors [8] . However, even with these therapeutic options, the prevalence of DN kept arising, and innovative treatment strategies were immediately required.…”