scholarly journals Current Guidelines for the Treatment of Arterial Hypertension in Patients with Diabetes Mellitus and Chronic Kidney Disease

2021 ◽  
Vol 17 (2) ◽  
pp. 323-331
Author(s):  
T. Yu. Demidova ◽  
O. A. Kislyak

The current understanding of the management of patients with diabetes mellitus (DM) based on the concept of the cardiovascular continuum involves not only the prevention and treatment of cardiovascular diseases (CVD), but also the prevention and treatment of chronic kidney disease (CKD). The fact is that patients with DM and CKD represent a special group of patients with a very high risk of CVD and cardiovascular mortality. Such patients require early diagnosis and timely identification of risk factors for the development and progression of CKD for their adequate correction. Arterial hypertension, along with hyperglycemia, is the main risk factor for the development and progression of CKD in patients with diabetes. In this regard, the choice of antihypertensive therapy (AHT) in patients with diabetes is of particular importance. The basis of AHT in diabetes and CKD is the combination of a blocker of the renin-angiotensin-aldosterone system (an angiotensin-converting enzyme inhibitor [ACE inhibitor] or an angiotensin II receptor blocker [ARB]) and a calcium channel blocker (CCB) or a thiazide / thiazide-like diuretic. The task of the performed AHT is to achieve the target level of blood pressure (BP). At the same time, the optimal blood pressure values in patients with diabetes and CKD are blood pressure values in the range of 130-139/70-79 mm Hg. If the target blood pressure is not achieved, it is necessary to intensify antihypertensive therapy by adding a third antihypertensive drug to the therapy: CCB or a diuretic (thiazide / thiazide-like or loop). In case of resistant hypertension, it is necessary to consider the possibility of adding antagonists of mineralocorticoid receptors, other diuretics or alpha-blockers to the conducted AHT. Beta-blockers can be added at any stage of therapy if the patient has exertional angina, a history of myocardial infarction, atrial fibrillation, and chronic heart failure. The need to normalize blood pressure parameters by prescribing combined antihypertensive therapy in patients with diabetes and CKD is explained by a decrease in renal and cardiovascular risks, and, therefore, a decrease in the risk of mortality in this cohort of patients.

2019 ◽  
Vol 23 (1) ◽  
pp. 37-44 ◽  
Author(s):  
O. B. Kuzmin ◽  
V. V. Zhezha ◽  
L. N. Landar ◽  
O. A. Salova

Arterial hypertension (AH) resistant to drug therapy is the phenotype of uncontrolled AH, in which patients receiving at least 3 antihypertensive drugs, including a diuretic, maintain blood pressure above the target level. Initially, the term refractory hypertension was also used to refer to resistant hypertension. Recently, however, refractory hypertension has been isolated into a separate phenotype of difficult to treat hypertension, which is defined as insufficient control of target blood pressure, despite the use of at least 5 different mechanisms of antihypertensive drugs, including long-acting diuretic and antagonist of mineralcorticoid receptors. Resistant hypertension is detected in 10–15 % of all hypertensive patients receiving drug therapy, and is often found in patients with chronic kidney disease. Hypertension can be a cause and/or consequence of kidney damage and is typical of most patients with chronic kidney disease. The lack of control of target blood pressure in a significant proportion of hypertensive patients with CKD who receive at least 3 antihypertensive drugs of different mechanisms of action indicates a lack of effectiveness of antihypertensive therapy, which not only accelerates the loss of renal function, but also significantly worsens the prognosis, contributing to such people risk of cardiovascular and renal complications. The review presents data on the prevalence, prognostic value of resistant hypertension in patients with chronic kidney disease, features of its formation and approaches to increasing the effectiveness of antihypertensive therapy in this patient population.


2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Kaori Takaori ◽  
Hirotsugu Iwatani ◽  
Masafumi Yamato ◽  
Takahito Ito

Abstract Background Vascular calcification is a prominent feature in chronic kidney disease (CKD) and diabetes mellitus. A recent report suggests that angiotensin II is protective to vascular calcification. Therefore, we investigated the relationship between vascular calcification and use of angiotensin-converting-enzyme inhibitor (ACEI) and/or angiotensin II receptor blocker (ARB) from a cross-sectional view. Methods A total of 121 predialysis CKD patients (age 71 ± 12 y; male 72; estimated glomerular filtration rate (eGFR) 20.2 (11.8 - 40.3) mL/min/1.73 m2) who underwent thoracoabdominal plain computed tomography scan were included in this study. The total vascular calcification volume (Calc) was calculated with a three-dimensional imaging software and standardized by body surface area (BSA). The relevance between log [Calc/BSA] and ACEI/ARB use was investigated by multivariate linear regression analyses with or without a time-duration factor of ACEI/ARB use. Results The Calc/BSA was 5.62 (2.01 - 12.7) mL/m2 in 121 patients. In multivariate analyses adjusted with age, sex, ACEI/ARB and log [eGFR], ACEI/ARB use is significantly and positively associated with log [Calc/BSA] (β = 0.2781, p = 0.0007). Even after the adjustment by age, sex, log [eGFR], phosphate, diabetes mellitus, systolic blood pressure, warfarin, hypertension, dyslipidemia, low-density lipoprotein cholesterol, diuretics and ACEI/ARB, ACEI/ARB use is significantly and positively associated with log [Calc/BSA] (β = 0.1677, p = 0.0487). When 90 patients whose time-duration of ACEI/ARB use was clear in medical records were studied, a multivariate analysis adjusted with age, sex, log [eGFR], and ACEI/ARB duration factors showed that the longer use of ACEI/ARB more than 2 years was significantly, independently and positively associated with log [Calc/BSA] (β = 0.2864, p = 0.0060). Conclusions ACEI/ARB user was associated with vascular calcification in predialysis patients with low eGFR. Prospective studies with larger numbers of patients or more in vitro studies are needed to confirm whether this phenomenon is due to the use of ACEI/ARB itself, the underlying disease condition or the prescription bias.


2019 ◽  
Vol 18 (1) ◽  
pp. 73-81 ◽  
Author(s):  
I. Е. Deneka ◽  
A. V. Rodionov ◽  
V. V. Fomin

Aim.To evaluate the effectiveness of telmisartan as a component of triple antihypertensive therapy in patients with obesity and refractory arterial hypertension.Material and methods.The study included 30 patients with obesity and refractory arterial hypertension. All patients received an angiotensin II receptor blocker (ARB) or an angiotensin-converting enzyme inhibitor (ACE inhibitor) in an adequate dosage as part of a triple antihypertensive therapy that also includes a calcium antagonist and thiazide diuretic. Participants were randomly divided into two equal groups. In the main group, telmisartan (Dr. Reddy’s Laboratories) was prescribed at a dosage of 80 mg/day instead of the previously taken ARB or ACE inhibitor. In the control group, patients continued to receive a previously prescribed ARB or an ACE inhibitor. The primary end point was a decrease in mean daily systolic and/or diastolic blood pressure (SBP and DBP) according to 24-hour blood pressure monitoring at 10 mm Hg and more than 20 weeks after the start of the study. The secondary end point was a decrease in the concentration of inflammatory markers and an increase in the level of adiponectin by 15%.Results.After 20 weeks, in the telmisartan group, we noted a significant decrease in the average daily SBP and DBP: in the main group from 145,9±5,4/95,6±4,8 mm Hg to 134,8±3,0/84,9±4,2 mm Hg, in the control group with 147,2±4,9/96,4±5,6 mm Hg to 142,4±4,3/96,9±62 mm Hg. We also determined an increase in the serum adiponectin concentration from 9,3±5,6 μg/ml to 13,4±6,6 μg/ml in the main group and a decrease from 8,8±5,2 μg/ml to 8,6±5,6 μg/ml in the control group, as well as a decrease in the concentration of highly sensitive C-reactive protein (main group from 8,8±3,0 to 6,0±2,8 mg/l and the control group from 7,4±3,8 to 6,9±4,9 mg/l) and interleukin-6 (main group from 16,2±6,1 to 12,3±2,8 pg/ml, control group from 22,5±4,2 to 19,9±5,2 pg/ml).Conclusion.Telmisartan can be considered as a drug of choice as part of multi-component therapy in the treatment of patients with obesity and refractor arterial hypertension.


2020 ◽  
Vol 16 (4) ◽  
pp. 623-634
Author(s):  
T. Yu. Demidova ◽  
O. A. Kislyak

Arterial hypertension (AH) is powerful and modifying factor of developing macrovascular and microvascular complications of diabetes. Patients with AH and diabetes belong to group with high and very high levels risk of developing cardiovascular complications and chronic kidney disease. The combination of type 2 diabetes mellitus and AH dramatically increases the risk of developing terminal stages of microvascular and macrovascular diabetic complications: blindness, end-stage chronic kidney disease, amputation of the lower extremities, myocardial infarction, cerebral stroke, worsens the patients prognosis and quality of life. There is ample evidence that blood pressure control in diabetic patients may be critical for improving long-term prognosis. This observation does not lose its relevance even with the emergence of new antidiabetic drugs with proven cardio- and nephroprotective effects. Modern clinical researchers and meta-analysis show the priority of combined antihypertensive therapy, which increases the efficacy of blood pressure correction and prophylaxis of long-term complications in patients with type 2 diabetes. In this article we want to pay attention to features of AH in patients with diabetes, to bi-directional pathogenic mechanisms, to discuss the new algorithms of the treatment and therapeutic needs of these patients. It is important to accent the understanding of the integrity and unity of pathogenic mechanisms which are needed in correction. Innovative antihyperglycemic therapy demonstrates the ability of blood pressure decrease. The synergy of effects let us successfully realize the strategy of multi-factor control and reduce a risk of micro- and macrovascular complications.


Author(s):  
Dmitriy Sergeevich Kovalev

Arterial hypertension is considered treatment refractory (resistant), if the treatment, involving a change (improvement) in lifestyle and a rational combined antihypertensive therapy, consisting of three drugs, including a diuretic, in the maximum tolerated doses does not lead to the achievement of the target blood pressure level. Pseudo-refractory and true refractory arterial hypertension are distinguished. According to modern data, true refractory arterial hypertension occurs in no more than 5 % of cases among the entire population of patients with arterial hypertension, however, in certain groups of patients, for instance, with chronic kidney disease, its prevalence can reach 30–50 %. The article presents a clinical case of diagnosis and treatment of refractory arterial hypertension.


CJC Open ◽  
2020 ◽  
Vol 2 (4) ◽  
pp. 258-264 ◽  
Author(s):  
Marcel Ruzicka ◽  
Greg Knoll ◽  
Frans H.H. Leenen ◽  
Judith Leech ◽  
Shawn D. Aaron ◽  
...  

2019 ◽  
Vol 2 (30) ◽  
pp. 6-11
Author(s):  
V. N. Karetnikova ◽  
T. N. Zvereva ◽  
O. L. Barbarash

The article presents an analysis of the current state of the problem of managing patients with arterial hypertension (AH) and various comorbid backgrounds. Also, it highlights the current guidelines (2018) for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. Information on new target blood pressure (BP) values in the range of 120–130 mm Hg is emphasized for systolic blood pressure (SBP) and 70–80 mm Hg for the diastolic (DAD) one in the majority of patients with the exception of persons of 65 years and older, as well as patients with chronic kidney disease, who have been recommended to achieve a blood pressure of 130–139 mm Hg. Furthermore, his material presents the current views on the priority of combined (initially double, and triple in the case of failure), mainly fixed antihypertensive therapy, the choice of which requires the presence and nature of comorbid pathology.


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