Rhode Island Kidney Care Connection
Furthering Kidney Health for Patients
With Diabetes
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The Effectiveness of ACEI/ARB Therapy in Slowing the Progession of Diabetes Complications and Chronic Kidney Disease
Introduction
Major medical standards and guidelines for care uniformly agree with the 2009 American Diabetes Association Standards of Care, which state: "Pharmacologic therapy for patients with diabetes and hypertension should be with a regimen that includes either an ACE inhibitor or an angiotensin receptor blocker (ARB) (1)." The standards also recommend that if one class of these agents is not tolerated, the other should be substituted, and that if needed to control hypertension, other antihypertensive agents should be added. These recommendations are supported by clinical trials demonstrating that ACEI or ARB therapy is generally protective against a variety of microvascular and macrovascular conditions (2,3). In patients with diabetes the use of these medications appears to reduce the occurrence of retinopathy (4) and of major cardiovascular events (3). In patients with diabetes and chronic kidney disease, ACEI/ARB therapy has been shown to reduce levels of proteinuria and slow progression toward kidney failure (5), and in these trials the benefits of ACEIs/ARBs appear to extend beyond their hypertension reduction effects. It has been suggested that the agonistic impact of these medications on the inflammatory effects of the renin-angiotensin system (RAS) may underlie these results (6).
Recent studies have attempted to clarify how best to employ these medications, particularly with regard to minimizing renal complications in diabetic patients. Addressing the question of whether combined ACEI and ARB therapy might be more protective than either (7), the ONTARGET study reported in 2008 that this combination therapy led to more complications, with no benefit over separate treatment with either agent (8). A series of trials addressing ACEI or ARB therapy for renal protection confirmed the ability of ACEIs or ARBs to slow the progression of CKD once kidney disease was present but found no differences in the proportions of diabetic patients without kidney disease who went on to develop nephropathy regardless of treatment with an ACEI or an ARB (4,9,10).
Conclusion While research continues on how best to modulate RAS and minimize kidney disease progression in patients with diabetes, an expert panel report from the Centers for Disease Control (CDC) proposes American medicine adopt a conceptual model of a public health approach to minimizing the impact of CKD (11). It proposes steps to enhance prevention of CKD (primary prevention), prevention of CKD progression and complications (secondary prevention), and more effective treatment of kidney failure (tertiary prevention). The use of ACEIs or ARBs is a predominant public health therapeutic strategy for both the primary and secondary prevention approaches of this panel. Until medical knowledge advances and we develop better agents and strategies for addressing CKD, the use of ACEIs or ARBs continues to provide physicians with the best chance of controlling kidney disease in their patients with diabetes.
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Kidney Disease Patients Benefit from Surgery to Prevent Stroke
Physicians should be comfortable referring some patients with chronic kidney disease (CKD) for effective stroke prevention surgery, according to a study appearing in an upcoming issue of the Journal of the American Society of Nephrology (JASN). The findings indicate that CKD patients gain a significant benefit from the procedures without an increased risk of dying from surgical complications.
For people who develop blockages in their arteries, physicians recommend surgery to clear the blood vessels and lower the risk of stroke. However, physicians are often hesitant to refer patients with CKD to undergo this type of surgery -- called carotid endarterectomy -- because CKD patients have a high risk of complications and death after undergoing invasive surgeries.
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