Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Author Reply
Book Review
Brief Communication
Case Report
Case Series
Clinical Case Report
Clinicopathological Conference
Commentary
Corrigendum
Editorial
Editorial – World Kidney Day 2016
Editorial Commentary
Erratum
Foreward
Guidelines
Image in Nephrology
Images in Nephrology
Letter to Editor
Letter to the Editor
Letters to Editor
Literature Review
Notice of Retraction
Obituary
Original Article
Perspective
Research Letter
Retraction Notice
Review
Review Article
Short Review
Special Article
Special Feature
Special Feature - World Kidney Day
Systematic Review
Technical Note
Varia
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Author Reply
Book Review
Brief Communication
Case Report
Case Series
Clinical Case Report
Clinicopathological Conference
Commentary
Corrigendum
Editorial
Editorial – World Kidney Day 2016
Editorial Commentary
Erratum
Foreward
Guidelines
Image in Nephrology
Images in Nephrology
Letter to Editor
Letter to the Editor
Letters to Editor
Literature Review
Notice of Retraction
Obituary
Original Article
Perspective
Research Letter
Retraction Notice
Review
Review Article
Short Review
Special Article
Special Feature
Special Feature - World Kidney Day
Systematic Review
Technical Note
Varia
View/Download PDF

Translate this page into:

Commentary
25 (
6
); 328-328
doi:
10.4103/0971-4065.168441

Dual therapy and diabetic kidney disease

Creator, Nephrology On-Demand, Charlotte, NC, USA 28075
Address for correspondence: Dr. T. Desai, 1601 Brenner Ave, Salisbury NC 28144, United States. E-mail: tejas.p.desai@gmail.com

Read COMMENTARY-ARTICLE associated with this -

Licence

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

Disclaimer:
This article was originally published by Medknow Publications & Media Pvt Ltd and was migrated to Scientific Scholar after the change of Publisher.

In this issue of the Indian Journal of Nephrology, Singh et al.[1] present a study that shows dual therapy with an angiotensin-converting enzyme (ACE) inhibitors and a fourth-generation dihydropyridine can reduce the amount of microalbuminuria in patients with diabetic kidney disease. Nephrologists have known for some time that albuminuria is an independent predictor of cardiovascular mortality, and that microalbuminuria (defined as a urine albumin: creatinine ratio of 30–300 mg/g) is an early detector of diabetic kidney disease. The results of this investigation are impressive; a reduction in microalbuminuria by more than 50% in patients administered both ACE inhibitors and dihydropyridine. These results, however, should be cautiously interpreted.

Interventions in the last five (5) years have suggested a disconnect between reductions in albuminuria and the progression of chronic kidney disease. In the BEAM and BEACON trials, an initial enthusiasm surrounding bardoxolone was dampened as reductions in albuminuria did not result in slowing of glomerular filtration rate (GFR) decline or death.[23] Subgroup analyses in the ALTITUDE trial showed a reduction in proteinuria with dual renin-angiotensin-aldosterone blockade; when looked at as a primary outcome in the Veterans Affairs Nephropathy in Diabetes trial, these results were complicated by higher rates of hyperkalemia and acute kidney injury.[45]

Thus far, only intensive glycemic control (glycosylated hemoglobin levels of < 6.5% as in the ADVANCE and ADVANCE-ON trials) has been proven to slow the progression of diabetic kidney disease.[67] Newer therapies, including endothelin receptor antagonists (e.g. atrasentan), have shown promise as anti-fibrotic agents, but their efficacy has been measured by reductions in albuminuria (RADAR trial).[8] The use of ACE inhibitors with dihydropyridines shows reductions in proteinuria similar to that seen with bardoxolone, dual ACE/angiotensin II receptor blockers, and atrasentan. Our hope is that additional studies with these agents show improvements in GFR decline and mortality.

References

  1. , , , , , , . Reduction of microalbuminuria in type-2 diabetes mellitus with angiotensin-converting enzyme inhibitor alone and with cilnidipine. Indian Journal of Nephrology. 2015;25:334-9.
    [Google Scholar]
  2. , , , , , , . Bardoxolone methyl and kidney function in CKD with type 2 diabetes. N Engl J Med. 2011;365:327-36.
    [Google Scholar]
  3. , , , , , , . Bardoxolone methyl in type 2 diabetes and stage 4 chronic kidney disease. N Engl J Med. 2013;369:2492-503.
    [Google Scholar]
  4. , , , , , , . Cardiorenal end points in a trial of aliskiren for type 2 diabetes. N Engl J Med. 2012;367:2204-13.
    [Google Scholar]
  5. , , , , , , . Combined angiotensin inhibition for the treatment of diabetic nephropathy. N Engl J Med. 2013;369:1892-903.
    [Google Scholar]
  6. , , , , , , . Intensive glucose control improves kidney outcomes in patients with type 2 diabetes. Kidney Int. 2013;83:517-23.
    [Google Scholar]
  7. , , , , , , . Follow-up of blood-pressure lowering and glucose control in type 2 diabetes. N Engl J Med. 2014;371:1392-406.
    [Google Scholar]
  8. , , , , , , . The endothelin antagonist atrasentan lowers residual albuminuria in patients with type 2 diabetic nephropathy. J Am Soc Nephrol. 2014;25:1083-93.
    [Google Scholar]

    Fulltext Views
    55

    PDF downloads
    48
    View/Download PDF
    Download Citations
    BibTeX
    RIS
    Show Sections