Adopting more aggressive strategies for the management of renal disease in type 2 diabetes

Diabetes and hypertension commonly co‐exist and this combination is associated with major morbidity and mortality from cardiovascular disease and diabetic nephropathy. Diabetic nephropathy is extremely common and increasing – it is associated with development of chronic renal failure and greatly increased cardiovascular morbidity. Elevated blood pressure is the principal factor in progression of diabetic nephropathy and tight blood pressure control is vital in delaying progression. There is now good evidence for involvement of the renin‐angiotensin system (RAS) in the pathogenesis of diabetic nephropathy and agents that inhibit this system (traditionally ACE inhibitors) may have beneficial effects on disease progression over and above their effects on systemic blood pressure. For this reason, ACE inhibitors are usually recommended first line although multiple antihypertensive therapies from different drug classes are normally required to reach target. More recently, other agents that block the RAS at the angiotensin II‐receptor site (angiotensin II‐receptor antagonists) have been developed. Three large studies have now been published in type 2 diabetes that demonstrate renal protective effects at both the stage of microalbuminuria (incipient nephropathy) and in patients with more advanced renal disease (overt nephropathy). Given the excellent tolerability profile of these agents and increasing evidence for renal protection, it is reasonable to suggest that angiotensin II‐receptor antagonists can also be considered as suitable first‐line agents in the management of hypertensive type 2 diabetic patients at risk of developing, or with overt, diabetic nephropathy.