ReviewAntihypertensive Therapy in the Presence of Proteinuria
Section snippets
The Natural History of Proteinuria
When evaluating the natural history of proteinuria, a distinction must be made between those with and without diabetes mellitus. Previous studies of patients with type 1 diabetes showed that average time from diagnosis of diabetes to the development of proteinuria is 19 years, and the strongest predictor of proteinuria is the presence of microalbuminuria.12, 13 This close association between the presence of microalbuminuria and subsequent development of proteinuria in patients with type 1
Role of Proteinuria in Setting BP Goals
All recent relevant guidelines recommend a BP goal less than 130/80 mm Hg for patients with diabetes and/or chronic kidney disease.2, 3, 24, 25 In patients with diabetes, the relevant evidence derives mainly from 2 outcome trials that randomly assigned subjects to different BP levels, the Hypertension Optimal Treatment trial26 and the United Kingdom Prospective Diabetes Study (UKPDS) 38,27 which showed significant decreases in cardiovascular mortality in the groups of patients with diabetes
Nonpharmacological Approaches
Overall, managing hypertension in Western societies on both sides of the Atlantic has proved very difficult because control rates are only about 30% in the United States and less than 10% of the overall hypertensive population in various European countries.34 The presence of chronic kidney disease makes hypertension management even harder. Such lifestyle changes as weight loss, exercise, and alcohol moderation should have a central role in helping manage hypertension in all patients, but
Conclusion
Proteinuria is a well known risk factor for the progression of renal disease and cardiovascular morbidity and mortality. To maximize risk reduction, physicians must focus on achieving a target BP less than 130/80 mm Hg in those with UAE greater than 300 mg/d (>0.3 g/d). ACE inhibitors and ARBs should be used as first-line antihypertensive therapy in patients with proteinuria because these classes have a BP-independent antiproteinuric effect and consistently were shown to improve renal and
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Originally published online as doi:10.1053/j.ajkd.2006.10.014 on December 1, 2006.
Support: None. Potential conflicts of interest: None.