Hypertension treatment in advanced diabetic nephropathy

Diabetes mellitus affects approximately 10% of the adult population. Diabetic nephropathy is the main etiology of end stage renal disease. Hypertension is extremely frequent among type 2 diabetes patients, being diagnosed prior to, simultaneously with or after diabetes itself Among type 1 diabetes patients hypertension is generally a consequence of diabetic nephropathy. Hypertension is a principal risk factor for cardiovascular disease and for nephropathy progression, while its treatment prevents cardiovascular and renal events. Pathophysiology of hypertension and nephropathy in diabetes involves increased sodium reabsorption and vasoconstriction mediated by upregulation of the renin angiotensin aldosterone system and imbalanced modulators of vascular tone. The general targets for hypertension treatment in diabetes patients are systolic < 130 mm Hg and diastolic < 80 mm Hg, which should be lower in proteinuric patients (< 125/75 mm Hg). To reach these targets patients should restrict dietary sodium to < 2 000 mg/day. First line drugs are the inhibitors of the renin-angiotensin-aldosterone system, because multiple studies showed they could delay renal disease progression. The algorithm for hypertension treatment in advanced diabetes nephropathy involves lifestyle counseling and multiple drug regimens which should be pathophysiologically oriented.