Diabetes and hypertension: how low should you go and with which drugs?

Diabetes and hypertension are the most common causes of end-stage renal disease in the United States. Both experimental and clinical studies have demonstrated the importance of more intensive control of systolic blood pressure (SBP) in delaying progression of renal disease, particularly in diabetic patients with macroproteinuria. Although traditional recommendations have suggested that reducing systolic to < 140 mm Hg is appropriate, there is consistent evidence in clinical trials demonstrating that, in the presence of diabetes, macroproteinuria, and impaired renal function, reducing systolic to < 125 mm Hg will result in a more successful attenuation of the rate of progression of renal disease. In addition, there is convincing evidence demonstrating that blockade of the renin angiotensin system, particularly with angiotensin converting enzyme inhibitors, results in an improved opportunity to delay progression of renal disease. Despite the advantages of angiotensin converting enzyme inhibitors, most patients will require three to five medications to achieve optimal levels of goal SBP to attenuate the rate of progression of renal disease.