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Drugs & Aging

, Volume 9, Issue 6, pp 449–457 | Cite as

Chemoprophylaxis of Diabetic Nephropathy in the Elderly

  • Eckart Jungmann
Review Article Drug Therapy
  • 6 Downloads

Summary

Renal disease in elderly diabetic patients is costly in terms of morbidity, mortality and medical payments. Therefore, prevention of diabetic nephropathy has become a prominent goal in the treatment of diabetic patients. Preventive treatment should begin not later than at the stage of persistent microalbuminuria, and regular screening for microalbuminuria is recommended for both elderly and younger diabetic patients.

Improved metabolic control, through diet and hypoglycaemic therapy, has been demonstrated to lower urinary albumin excretion. The target level of glycated haemoglobin is <8%, or <2% higher than the upper limit of normal in nondiabetic people. Insulin therapy has no adverse effects on renal indices, unless it increases bodyweight and consequently raises blood pressure.

To preserve renal function in elderly diabetic patients, blood pressure should be kept well below 140/90mm Hg. Treatment with ACE inhibitors may be the ‘gold standard’ intervention, and should be initiated at the lowest possible dosage and then titrated until the maximum tolerated dosage has been reached. Nonchronotropic calcium antagonists have been shown to be as effective as ACE inhibitors with regard to their effects on blood pressure, renal haemodynamics and urinary albumin excretion. Most dihydropyridines have been found to increase or to have no effect on urinary albumin excretion despite significant blood pressure reduction.

A renoprotective action of diuretics is generally unlikely, with the possible exception of indapamide. Although β-blockers are effective antihypertensive agents, they may not adequately preserve kidney function in diabetic patients. Because β-blocker treatment may mask the symptoms of hypoglycaemia, they should be reserved for patients with coronary artery disease or arrhythmias.

Keywords

Diabetic Nephropathy Calcium Antagonist Urinary Albumin Urinary Albumin Excretion Nitrendipine 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Jungmann E, Usadel KH. Renal long-term effects of calcium antagonist treatment in patients with diabetes mellitus. Clin Investig 1992; 70: 942–8PubMedCrossRefGoogle Scholar
  2. 2.
    Jungmann E, Carlberg C, Schallmayer M, et al. Albuminuria in patients with type 2 diabetes mellitus: impact of blood pressure and metabolic control [in German]. Med Klin 1995; 90: 383–9Google Scholar
  3. 3.
    Mogensen CE, Keane WF, Bennett PH, et al. Prevention of diabetic renal disease with special reference to microalbuminuria. Lancet 1995 Oct 21; 346: 1080–4PubMedCrossRefGoogle Scholar
  4. 4.
    Ritz E. Hypertension in diabetic nephropathy: prevention and treatment. Am Heart J 1993; 125: 1514–9PubMedCrossRefGoogle Scholar
  5. 5.
    Singh I, Marshall MC. Diabetes mellitus in the elderly. Endocrinol Metab Clin North Am 1995; 24(2): 255–72PubMedGoogle Scholar
  6. 6.
    United States Renal Data System 1990 Annual Report. Am J Kidney Dis 1990; 16 Suppl. 2: 22–7Google Scholar
  7. 7.
    Viberti JC, Yip-Messent J, Morocutti A. Diabetic nephropathy: future avenue. Diab Care 1992; 15: 1216–25CrossRefGoogle Scholar
  8. 8.
    Walker WG, Hermann J, Murphy RP, et al. Prospective study of the impact of hypertension upon kidney function in diabetes mellitus. Nephron 1990; 55 Suppl. 1: 21–6PubMedCrossRefGoogle Scholar
  9. 9.
    Rossing P, Hommel E, Smidt UM, et al. Reduction in albuminuria predicts a beneficial effect on diminishing the progression of human diabetic nephropathy during antihypertensive treatment. Diabetologia 1994; 37: 511–6PubMedCrossRefGoogle Scholar
  10. 10.
    Wirta O, Pasternack A, Mustonen J, et al. Albumin excretion rate and its relation to kidney disease in non-insulin dependent diabetes mellitus. J Intern Med 1995; 237: 367–73PubMedCrossRefGoogle Scholar
  11. 11.
    Nelson RG, Pettitt DJ, Baird HR, et al. Pre-diabetic blood pressure predicts urinary albumin excretion after the onset of type 2 diabetes mellitus in Pima Indians. Diabetologia 1993; 36: 998–1001PubMedCrossRefGoogle Scholar
  12. 12.
    Schmitz A, Vaeth M, Mogensen CE. Systolic blood pressure relates to the rate of progression of albuminuria in NIDDM. Diabetologia 1994; 37: 1251–8PubMedCrossRefGoogle Scholar
  13. 13.
    Schmitz A, Vaeth M. Microalbuminuria: a major risk factor in non-insulin-dependent diabetes. A 10-year follow-up study of 503 patients. Diabet Med 1988; 5: 126–34PubMedCrossRefGoogle Scholar
  14. 14.
    Walker PJ. Chronic complications of diabetes. In: Finucane P, Sinclair AJ, editors. Diabetes in old age. Chichester: John Wiley & Sons, 1995: 107–36Google Scholar
  15. 15.
    The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329: 977–86CrossRefGoogle Scholar
  16. 16.
    Deckert T, Feldt-Rasmussen B, Borch-Johnsen K, et al. Albuminuria reflects widespread vascular damage: the Steno hypothesis. Diabetologia 1989; 32: 219–26PubMedCrossRefGoogle Scholar
  17. 17.
    Krolewski AS, Laffel LMB, Krolewski M, et al. Glycosylated hemoglobin and the risk of microalbuminuria in patients with insulin-dependent diabetes mellitus. N Engl J Med 1995; 332: 1251–5PubMedCrossRefGoogle Scholar
  18. 18.
    Wang PH, Lau J, Chalmers TC. Meta-analysis of effects of intensive blood glucose control on late complications of type 1 diabetes. Lancet 1993; 341: 1306–9PubMedCrossRefGoogle Scholar
  19. 19.
    Schmitz A. Renal function changes in middle-aged and elderly Caucasian type 2 diabetic patients — a review. Diabetologia 1993; 36: 985–92PubMedCrossRefGoogle Scholar
  20. 20.
    UK Prospective Diabetes Study Group: UK Prospective Diabetes Study IX. Relationships of urinary albumin and N-acetylglucosaminidase to glycaemia and hypertension at diagnosis of type 2 diabetes mellitus and after 3 months’ diet therapy. Diabetologia 1993; 36: 835–42CrossRefGoogle Scholar
  21. 21.
    Schmitz A, Hvid Hansen H, Christensen T. Kidney function in newly diagnosed type 2 diabetic patients, before and during treatment. Diabetologia 1989; 32: 434–9PubMedCrossRefGoogle Scholar
  22. 22.
    Vora JP, Dolben J, Williams JD, et al. Impact of initial treatment on renal function in newly-diagnosed type 2 diabetes mellitus. Diabetologia 1993; 36: 734–40PubMedCrossRefGoogle Scholar
  23. 23.
    Campbell IW, Menzies DG, Chalmers J, et al. One year comparative trial of metformin and glipizide in type 2 diabetes mellitus. Diabete Metab 1994; 20: 394–400PubMedGoogle Scholar
  24. 24.
    Jerums G, Murray RML, Seeman E, et al. Lack of effect of gliclazide on early diabetic nephropathy and retinopathy: a two-year controlled study. Diabetes Res Clin Pract 1987; 3: 71–80PubMedCrossRefGoogle Scholar
  25. 25.
    Wolffenbuttel BHR, van Haeften TW. Prevention of complications in non-insulin-dependent diabetes mellitus (NIDDM). Drugs 1995; 50(2): 263–88PubMedCrossRefGoogle Scholar
  26. 26.
    Jungmann E, Carlberg C, Schumm-Draeger PM. Impact of glycaemic control on urinary albumin excretion in patients with type 2 diabetes mellitus. Diabetologia 1994; 37: 441–2PubMedCrossRefGoogle Scholar
  27. 27.
    Randeree HA, Omar MAK, Motala AA, et al. Effect of insulin therapy on blood pressure in NIDDM patients with secondary failure. Diabetes Care 1992; 15: 1258–63PubMedCrossRefGoogle Scholar
  28. 28.
    Tedde R, Sechi LA, Marigliano A, et al. Antihypertensive effect of insulin reduction in diabetic-hypertensive patients. Am J Hypertens 1989; 2: 163–70PubMedGoogle Scholar
  29. 29.
    Dodson PM, Beevers M, Hallworth R, et al. Sodium restriction and blood pressure in hypertensive type II diabetics: randomised blind controlled and crossover studies of moderate sodium restriction and sodium supplementation. BMJ 1989; 298: 227–30PubMedCrossRefGoogle Scholar
  30. 30.
    Jungmann E. Diabetic sodium retention [in German]. Nieren- und Hochdruckkrh 1992; 21: 709–15Google Scholar
  31. 31.
    Zeller K, Whittaker E, Sullivan L, et al. Effect of restricting dietary protein on the progression of renal failure in patients with insulin-dependent diabetes mellitus. N Engl J Med 1991; 324: 78–84PubMedCrossRefGoogle Scholar
  32. 32.
    Weidmann P, Boehlen LM, de Courten M. Pathogenesis and treatment of hypertension associated with diabetes mellitus. Am Heart J 1993; 125: 1498–513PubMedCrossRefGoogle Scholar
  33. 33.
    Parving HH, Andersen AR, Smidt UM, et al. Effect of antihypertensive treatment on kidney function in diabetic nephropathy. BMJ 1987; 294: 1443–7PubMedCrossRefGoogle Scholar
  34. 34.
    Arrauz-Pacheco C, Raskin P. Management of hypertension in diabetes. Endocrinol Metab Clin North Am 1992; 21: 371–94Google Scholar
  35. 35.
    Jungmann E, Krüger K, Semler B, et al. The renoprotective effect of the converting-enzyme inhibitor ramipril in hypertensive patients with insulin-treated type II diabetes mellitus [in German]. Nieren- und Hochdruckkrh 1995; 24: 248–50Google Scholar
  36. 36.
    Anderson S. Renal effects of converting enzyme inhibitors in hypertension and diabetes. J Cardiovasc Pharmacol 1990; 15 Suppl. 3: S11–5PubMedCrossRefGoogle Scholar
  37. 37.
    Ravid M, Savin H, Jutrin I, et al. Long-term stabilizing effect of angiotensin-converting enzyme inhibition on plasma creatinine and on proteinuria in normotensive type II diabetic patients. Ann Intern Med 1993 Apr 15; 118: 577–81PubMedGoogle Scholar
  38. 38.
    Lewis EJ, Hunsicker LG, Brain KRP, et al. The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. N Engl J Med 1993 Nov 11; 329: 1456–62PubMedCrossRefGoogle Scholar
  39. 39.
    Kasiske BL, Kalil RSN, Ma ZZ, et al. Effect of antihypertensive therapy on the kidney in patients with diabetes: a meta-regression analysis. Ann Intern Med 1993; 118: 129–38PubMedGoogle Scholar
  40. 40.
    Heeg JE, De Jong PE, von der Hem GK, et al. Efficacy and variability of the antiproteinuric effect of ACE inhibition by lisinopril. Kidney Int 1989; 36: 272–9PubMedCrossRefGoogle Scholar
  41. 41.
    Haller H. Hyperglycaemia and hyperinsulinaemia as important factors in the pathogenesis of diabetic angiopathy. In: Parving HH, editor. The hypertensive diabetic in focus. St Ives: Pope Woodhead & Associates, 1993: 10–20Google Scholar
  42. 42.
    Bakris GL. Hypertension in diabetic patients: an overview of interventional studies to preserve renal function. Am J Hypertens 1993; 6 Suppl. 4: 140S–7SPubMedGoogle Scholar
  43. 43.
    Ruggenenti P, Mosconi L, Bianchi L, et al. Long-term treatment with either enalapril or nitrendipine stabilizes albuminuria and increases glomerular filtration rate in non-insulin-dependent diabetic patients. Am J Kidney Dis 1994; 24: 753–63PubMedGoogle Scholar
  44. 44.
    Bretzel RG, Bollen CC, Maeser E, et al. Nephroprotective effects of nitrendipine in hypertensive type 1 and type 2 diabetic patients. Am J Kidney Dis 1993; 21 Suppl. 3: 53–64PubMedGoogle Scholar
  45. 45.
    Jungmann E. Renal action of nitrendipine in normotensive patients with type 1 diabetes mellitus. Cardiovasc Risk Factors 1994; 4 Suppl. 1: 51–6Google Scholar
  46. 46.
    Haak E, Haak T, Schumm-Draeger PM, et al. Effect of 4-year nitrendipine treatment on microalbuminuria in normotensive patients with type 1 diabetes mellitus [abstract] [in German]. Med Klin 1995; 90 Suppl. II: 77Google Scholar
  47. 47.
    Hoelscher D, Bakris G. Antihypertensive therapy and progression of diabetic renal disease. J Cardiovasc Pharmacol 1994; 23 Suppl. 1: S34–8PubMedCrossRefGoogle Scholar
  48. 48.
    Stornello M, Valvo EV, Scapellato L. Hemodynamic, renal and humoral effects of the calcium entry blocker nicardipine and converting enzyme inhibitor captopril in hypertensive type II diabetic patients with nephropathy. J Cardiovasc Pharmacol 1989; 14: 851–5PubMedCrossRefGoogle Scholar
  49. 49.
    Josefsberg Z, Ross SA, Fick GH, et al. Comparison of nitrendipine and enalapril on the effects of microalbuminuria and metabolic parameters in hypertensive non-insulin-dependent diabetic subjects. In: Parving HH, editor. The hypertensive diabetic in focus. St Ives: Pope Woodhead & Associates, 1993: 40–7Google Scholar
  50. 50.
    Gambardella S, Frontoni S, Felici MG, et al. Efficacy of antihypertensive treatment with indapamide in patients with non-insulin-dependent diabetes and persistent microalbuminuria. Am J Cardiol 1990 May 2; 65 Suppl.: 46H–50HGoogle Scholar
  51. 51.
    Stornello M, Valvo EV, Scapellato L. Comparative effects of enalapril, atenolol and chlorthalidone on blood pressure and kidney function of diabetic patients affected by arterial hypertension and persistent proteinuria. Nephron 1991; 58: 52–7PubMedCrossRefGoogle Scholar
  52. 52.
    Nielsen FS, Rossing P, Gall MA, et al. Impact of lisinopril and atenolol on kidney function in hypertensive NIDDM subjects with diabetic nephropathy. Diabetes 1994; 43: 1108–13PubMedCrossRefGoogle Scholar
  53. 53.
    Schernthaner G, Schnack C, Hopmeier P. Effect of ramipril or atenolol on microalbuminuria and metabolic control parameters in type-2 diabetes mellitus [abstract]. Diabetologia 1994; 37 Suppl. 1: A195Google Scholar

Copyright information

© Adis International Limited 1996

Authors and Affiliations

  • Eckart Jungmann
    • 1
  1. 1.Endocrine and Diabetes UnitSt Vincent’s Hospital WiedenbrückRheda-WiedenbrückGermany

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