1.
Lessons from the African-American Study of Kidney Disease and Hypertension: an update.
Toto, RD
Current hypertension reports. 2006;(5):409-12
Abstract
Hypertension is the second leading attributable cause of end-stage renal disease in the United States today. The African-American Study of Kidney Disease and Hypertension was a randomized, double-blind, controlled trial designed to determine whether strict blood pressure (BP) control, angiotensin-converting enzyme inhibitor (ACEI)-based, or calcium channel blocker (CCB)-based regimens were superior to less strict BP control and beta-blocker (BB)-based regimens, respectively. The study enrolled 1093 African Americans with hypertensive nephrosclerosis and followed them for 4 years with repeated direct measurement of glomerular filtration rate (GFR) and monitoring of end points, including rapid decline in GFR, end-stage kidney disease, and death. From this landmark study, we learned that strict BP control is achievable in this study population, but it did not slow progression of kidney disease, and we learned that an ACEI-based therapy was superior to either a BB- or CCB-based regimen. In addition, we learned that proteinuria is the most important predictor of progression of kidney disease; ACEI and CCB have differential effects on proteinuria; and a CCB-based regimen combined with strict BP control may be the next best choice to an ACEI-based regimen in this population.
2.
Advantages of a third-generation beta-blocker in patients with diabetes mellitus.
Bell, DS
The American journal of cardiology. 2004;(9A):49B-52B
Abstract
beta-Blocker use improves outcomes even more for the patient with diabetes mellitus than for the patient without diabetes with a history of acute myocardial infarction or coronary artery disease. beta-Blockers facilitate shifting the metabolism of the myocardium away from free fatty acid toward glucose utilization, thereby reducing the cardiac workload and myocardial ischemia. beta-Blockers are also able to reverse the fetal gene induction program to reverse myocardial remodeling and improve ventricular function. Side effects of beta-blockers in the patient with diabetes include increased insulin resistance with worsening glycemic control, elevated triglyceride levels, and lowered levels of high-density lipoprotein cholesterol. Increased frequency of hypoglycemia and its lack of recognition can also be a problem in the insulin-deficient patient but is a minimal problem with the patient with type 2 diabetes. In addition, vasoconstriction, caused by unopposed alpha-activity, can worsen peripheral vascular disease. However, carvedilol, a nonselective beta-blocker with vasodilating and insulin-sensitizing properties, can largely circumvent these problems and is the ideal beta-blocker for the patient with diabetes.