Slowing the progression of renal disease in diabetic patients

OBJECTIVE: To review recent clinical trials that evaluate the most appropriate therapeutic options for delaying the progression of nephropathy in type 2 diabetic patients. DATA SOURCES: Primary and review articles were retrieved through a MEDLINE search (January 1990-January 2000). STUDY SELECTION AND DATA EXTRACTION: All studies related to attenuating the progression of nephropathy in diabetic patients were evaluated and included in this review. DATA SYNTHESIS: Clinical trials with angiotensin-converting enzyme inhibitors (ACEI) have consistently demonstrated a decrease in the progression of renal disease in diabetic patients. The angiotensin-2 receptor blocker (ARB) losartan has been shown to reduce microalbuminuria to the same extent as the ACEI enalapril. The nondihydropyridine calcium-channel blockers (NCCBs) verapamil and diltiazem have also been shown to decrease urinary albumin excretion. Clinical literature suggests that if monotherapy with an ACEI or ARB does not provide an adequate response, an NCCB should be added to the regimen. CONCLUSIONS: ACEIs should be considered first-line therapy for diabetic patients with nephropathy. ARBs should be considered as an alternative for patients who are unable to tolerate an ACE inhibitor due to adverse effects. If blood pressure goals are not achieved with an ACEI or ARB, then the addition of an NCCB should be considered.

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