Volume 1, Number 3, September 2000

ACE inhibitors and antihypertensive treatment in diabetes: focus on microalbuminuria and macrovascular disease
Carl Erik Mogensen

Hypertension is a common complication of diabetes mellitus. The origins of increased blood pressure (BP) differ between the two types of diabetes. In Type 1 diabetes, the increase in BP is closely linked to the onset and progression of renal disease and is a major risk factor for overt nephropathy. In Type 2 diabetes, by contrast, because of the older age of the patient group, macrovascular and cardiac complications of hypertension are more prominent. In recent years, a number of clinical trials have been performed to investigate the effects of antihypertensive treatment on diabetic vascular and renal disease.
The United Kingdom Prospective Diabetes (UKPDS) study showed that the effect of BP-lowering on several diabetic complications was more rapid and more pronounced than the effects of glycaemic control. Among the diabetic patients recruited to the Hypertension Optimal Treatment (HOT) study, tighter BP control resulted in fewer cardiovascular complications. The conclusions from these, and other studies, is that more aggressive BP control is recommended in the treatment of Type 2 diabetes.
Microalbuminuria, the herald of diabetic renal damage, predicts the future progression of renal disease. Follow-up data from the DCCT database shows that the onset of microalbuminuria in Type 1 diabetes is closely followed by an increase in BP. Thereafter, microalbuminuria increases by 15–20% per year, depending on the degree of BP and glycaemic control. Antihypertensive therapy, particularly angiotensin-converting enzyme (ACE) inhibition, has been shown to decrease urinary albumin excretion. Additionally, antihypertensive therapy can slow the progression of renal structural damage and a combination of ACE inhibitors and diuretics has been shown to preserve glomerular filtration rate (GFR).
On the basis of these findings, it is widely recommended that diabetics be screened for microalbuminuria and intervention started early in the course of microalbuminuria to prevent deterioration in renal function.

JRAAS 2000;1:234-239.

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