What is the optimal strategy to intensify blood pressure control and prevent progression of renal failure?

Recent clinical trials clearly demonstrate that patients with diabetes and hypertension, and patients with renal disease and hypertension, should have their blood pressure lowered intensively. A recent analysis of long-term clinical trials over the past 8 years clearly demonstrates that the lower the blood pressure over a range of values, the greater the preservation of renal function. It is also readily apparent that monotherapy does not suffice in attaining these more intensified goals. A review of five clinical trials in the recent National Kidney Foundation consensus report demonstrates that patients randomized to the lower level of blood pressure required an average of 3.2 different antihypertensive medications taken daily. Consequently, it is evident that the question is no longer what the initial preferred monotherapy should be, but rather what should be the optimal drug to add to an angiotensin converting enzyme inhibitor or angiotensin receptor blocker. In this paper we review data from several recent studies clearly indicating that to achieve goal blood pressure in the clinical setting of metabolic disarray and hyperglycemia, long-acting calcium antagonists constitute an excellent add-on agent for enhancing efficacy. We anticipate that the data that will accrue from the IDNT and RENAAL studies will further delineate the renal effects of dihydropyridine calcium antagonists.