Renal involvement in hypertensive cardiovascular disease

Cardiovascular morbidity and mortality are elevated in renally impaired patients, especially if they are hypertensive. Diabetes is also associated with a high prevalence of cardiovascular morbidity and end-stage renal disease. Albuminuria, elevated serum creatinine, decreased creatinine clearance and proteinuria independently predict cardiovascular risk. Even patients with mild renal impairment should be treated to slow kidney disease progression and reduce vascular damage. Blood pressure control is effective in reducing vascular complications of diabetes, but not all classes of antihypertensive agents provide renoprotection. Angiotensin-converting enzyme inhibitors are superior to beta-blockers in preventing or delaying the loss of kidney function associated with hypertension. The renoprotection appears to be in part independent of the antihypertensive effect. Angiotensin II receptor blockers (ARBs) also reduce the risk of renal complications in diabetics. Telmisartan seems well suited to provide renoprotection because, unlike other ARBs, it is almost exclusively excreted by the liver and no initial dose adjustment is required for patients with mild-to-moderate renal impairment. Other advantages of telmisartan include its very high volume of distribution and long terminal elemination half-life. Clinical trials to evaluate telmisartan will address the problems of diabetes, renal impairment and end-organ disease.