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Management of Hypertension in Diabetic Patients With Chronic Kidney Disease. Diabetes Spectrum. 21(1):30-36.Winter 2008.

Diabetes is associated with markedly increased cardiovascular risk, a risk that is made worse by the presence of chronic kidney disease (CKD), a common complication of diabetes. More than 80 percent of people with diabetes and CKD have hypertension. This review, from a special section about managing patients with diabetes and CKD, discusses the evidence regarding one of the most important treatment targets for patients with CKD: control of blood pressure to less than 130/80 mmHg. The author provides detailed information about appropriate blood pressure measurement and treatments to best achieve that target. Careful blood pressure measurement, a multiple risk factor modification strategy, and persistent and judicious renin-angiotensin-aldosterone system (RAAS) blockade in combination with diuretics and add-ons should result in good blood pressure control in most patients. In addition, engaging patients and their families through home-based blood pressure measurement (HBP), lifestyle modification, and collaboration with clinic nurses, pharmacists, and other health care providers will facilitate success. 2 tables. 57 references.

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Management of Hypertension in Diabetic Patients With Chronic Kidney Disease. Diabetes Spectrum. 21(1): 30-36. Winter 2008.

Diabetes is associated with markedly increased cardiovascular risk, a risk that is made worse by the presence of chronic kidney disease (CKD), a common complication of diabetes. More than 80 percent of people with diabetes and CKD have hypertension. This review from a special section on managing patients with diabetes and CKD, called diabetic kidney disease (DKD), discusses the evidence regarding one of the most important treatment targets for these patients, namely, control of blood pressure to less than 130/80 millimeters of mercury (mmHg). The author provides detailed information about appropriate blood pressure measurement and treatments to best achieve that target. Careful blood pressure measurement, a multiple risk factor modification strategy, and persistent and judicious renin-angiotensin-aldosterone system (RAAS) blockade in combination with diuretics and add-ons should result in good blood pressure control in a majority of patients. In addition, engaging patients and their families through home-based blood pressure measurement (HBP), lifestyle modification, and collaboration with clinic nurses, pharmacists, and other health care providers will facilitate success. 2 tables. 57 references.

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Endocrine Hypertension. IN: Gardner, D.; Shoback, D., eds. Greenspan’s Basic and Clinical Endocrinology. 8th ed. Columbus, OH: McGraw Hill. 2007. pp 396-420.

This chapter about endocrine hypertension is from a textbook about endocrinology that describes the scientific principles and clinical management of patients with endocrine-related diseases and disorders. The authors note that although the kidney is not an endocrine organ per se, its role as both the origin of and target tissue for the hormones that comprise the renin-angiotensin-aldosterone system make hypertensive disorders of kidney origin an appropriate subject for a chapter on endocrine hypertension. Hypertension can be a prominent feature of other endocrine disorders, including acromegaly, thyrotoxicosis, hypothyroidism, and hyperparathyroidism, but these are discussed elsewhere in the text. In this chapter, the authors discuss the synthesis, metabolism, and action of mineralocorticoid hormones; the pathogenesis of mineralocorticoid hypertension; aldosterone and the heart; primary aldosteronism; syndromes due to excess deoxycorticosterone production; Cushing’s syndrome; pseudohyperaldosteronism; hypertension of renal origin; the renin-angiotensin system and hypertension; and other hormone systems and hypertension, including insulin, the natriuretic peptides, nitric oxide, endothelin, the kallikrein-kinin system, and the sympathetic nervous system. The chapter includes numerous black-and-white photographs and illustrations; a list of abbreviations is provided. 11 figures. 1 table. 15 references.

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American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Hypertension. Endocrine Practice. 12(2): 193-222. March-April 2006.

This article presents the American Association of Clinical Endocrinologists (AACE) medical guidelines for clinical practice for the diagnosis and treatment of hypertension. The guidelines focus on identifying and managing hypertension secondary to or coincident with endocrinopathies, such as diabetes mellitus. The AACE contends that understanding the associated pathophysiologic features of hypertension will guide appropriate treatment and thus help physicians anticipate the usefulness of evolving therapies, such as blockade of the renin-angiotensin systems for retarding the progression of retinopathy and nephropathy in patients with diabetes. The objectives of the guidelines are to indicate when to suspect the presence of and pursue further testing for secondary hypertension; provide appropriate examples of the most common causes of endocrine-associated hypertension that physicians my encounter; elucidate the cause of each endocrine disorder underlying hypertension; describe the tests used to confirm each diagnosis; identify the appropriate management options for each condition based on the available evidence and known pathophysiologic changes; and discuss outcomes and potential side effects associated with each management option. In addition to diabetes, the guidelines cover coronary or peripheral vascular disease; glucocorticoid excess (Cushing’s syndrome); genetic diseases; disorders of the adrenal, thyroid, parathyroid, and pituitary glands; abnormal renal tubular sodium handling; and renin-secreting tumors. 3 figures. 7 tables. 187 references.

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Angiotensin II and Its Receptors in the Pathogenesis of Diabetic Nephropathy. IN: Cortes, P. and Mogensen, C.E., eds. Diabetic Kidney. Totowa, NJ: Humana Press. 2006. pp. 3-21.

This chapter on angiotensin II and its receptors in the pathogenesis of diabetic nephropathy is from a clinical textbook on the diabetic kidney. After a brief introduction, the authors cover the renin-angiotensin system (RAS) in diabetes, angiotensin II receptors, the mechanisms of action of angiotensin II receptors, and future directions for research in this area. Diabetic nephropathy (DN) is characterized by the accumulation of extracellular matrix (ECM) in the kidney. The peptide angiotensin II has many hemodynamic and biochemical effects that could contribute to DN. The authors conclude that recent research suggests that angiotensin II may act as a signaling peptide to initiate transcriptional changes for particular genes. In view of these findings, it is imperative to study the localization of nuclear angiotensin II receptors and their role in the regulation of gene transcription and expression of matrix proteins in glomerular mesangial cells. The chapter begins with an outline of the topics covered and ends with an extensive list of references. 10 figures. 1 table. 95 references.

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Diabetic Renal and Related Heart Disease: ACE Inhibitors and/or Angiotensin Receptor Blockers: Does It Matter?. IN: Cortes, P. and Mogensen, C.E., eds. Diabetic Kidney. Totowa, NJ: Humana Press. 2006. pp. 437-452.

This chapter on diabetic renal and related heart disease is from a clinical textbook on the diabetic kidney. After a brief introduction, the authors focus on the role of Angiotension-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). Topics include the use of ACE inhibitors versus beta blockers and diuretics, antihypertensives that may confer an increased risk for the development of new diabetes, strategies to prevent microalbuminuria in diabetes, research studies of the impact of ACE inhibitors and ARBs on renal outcomes and mortality, and the use of ACE inhibitors or ARBs in patients with congestive heart failure. The authors conclude that although any type of blood pressure reduction is important in patients with diabetes, blocking the renin-angiotensin system (RAS) is the most important strategy in both type 1 and type 2 diabetes patients. Both classes of drugs discussed (ACE inhibitors and ARBs) provide the same benefits, preventing progression of renal disease. Regarding heart failure, ACE inhibition is a well-established part of heart failure treatment, but the role of ARBs is not fully determined. The chapter begins with an outline of the topics covered and ends with an extensive list of references. 3 tables. 67 references.

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Disorders of the Adrenal Cortex. IN: Jameson, J.L., ed. Harrison's Endocrinology. Columbus, OH: McGraw Hill. 2006. pp 113-150.

This chapter on disorders of the adrenal cortex is from a textbook that offers a comprehensive, practical look at the field of endocrinology. The adrenal cortex produces three major classes of steroids: glucocorticoids, mineralocorticoids, and adrenal androgens. Thus, normal adrenal function is involved in modulating intermediary metabolism and immune responses; blood pressure, vascular volume, and electrolytes; and secondary sexual characteristics in females. The authors discuss biochemistry and physiology, the laboratory evaluation of adrenocortical function, hyperfunction of the adrenal cortex including Cushing's syndrome and aldosteronism, hypofunction of the adrenal cortex, hypoaldosteronism, and the pharmacologic clinical uses of adrenal steroids. Specific topics covered include steroid nomenclature, the biosynthesis of adrenal steroids, steroid transport, steroid metabolism and excretion, adrenocorticotropic hormone (ACTH) physiology, renin-angiotensin physiology, glucocorticoid physiology, mineralocorticoid physiology, and androgen physiology. The chapter includes full-color illustrations and black-and-white photographs. 11 figures. 11 tables. 16 references.

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Do Oral Contraceptives Pose a Risk to Diabetic Kidneys?. Consultant. 46(1): 14. January 2006.

This brief article considers the interplay of oral contraceptives and kidney complications of diabetes mellitus (diabetic nephropathy). The author first reviews the benefits of certain antihypertensive medications, notably ACE inhibitors and angiotensin receptor blockers (ARBs), for inhibiting the renin-angiotensin system and thus protecting the kidneys. In contrast, oral contraceptives can activate the renin-angiotensin system in healthy women and they might therefore have adverse effects on the kidneys of women with diabetes. The author reports on a study in which macroalbuminuria (protein in the urine) developed in 18 percent of women with diabetes who were on oral contraceptives, compared with 2 percent of nonusers. The author concludes that a large prospective trial is required to determine definitively whether the risk of renal disease is real enough to lead to a change in the way in which oral contraceptives are prescribed for women with diabetes. 3 references.

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Hypertension and the Kidney. Seminars in Nephrology. 25(4): 236-245. July 2005.

Hypertension (high blood pressure) is an important and widely prevalent risk factor for the development of chronic kidney disease (CKD), which can subsequently progress to end stage renal disease (ESRD). This article reviews the impact of hypertension on the kidney, with an emphasis on patients with diabetes mellitus. The authors note that diabetes is another cause of CKD and that aggressive control of hypertension and diabetes is indicated to reduce the risk for kidney disease in the community. The concept of decreasing the systemic blood pressure as well as the intraglomerular (within the kidney) pressure has led to the application of rational treatment options in patients with chronic renal insufficiency (CRI). The authors stress that antihypertensive agents that also block the renin-angiotensin system have been shown to have special renal (kidney) and cardiovascular benefits. Early detection and treatment of microalbuminuria (microscopic protein in the urine) is an important part of disease management. Topics discussed include primary glomerular disease, hypertensive nephrosclerosis, cardiovascular disease risk, nonpharmacologic (lifestyle) treatment strategies, monitoring blood pressure response, and hypertension in patients on hemodialysis. 3 figures. 3 tables. 101 references.

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Hypertension in Hemodialysis. In: Clinical Dialysis. 4th ed. New York, NY: McGraw-Hill. 2005. pp. 755-776.

Hypertension occurs very frequently in chronic kidney disease (CKD) and is nearly universal in patients who reach end stage renal disease (ESRD). This chapter on hypertension in hemodialysis is from a comprehensive textbook on the clinical management of patients on dialysis. The author discusses the etiology of hypertension, rationalizes the measurement of blood pressure (BP), discusses the relationship between BP and adverse outcomes, and outlines the pharmacologic and nonpharmacologic therapies used to control hypertension in this patient population. Specific topics include increased cardiac output due to increased sodium and extracellular fluid volume, the renin-angiotensin system, circulating inhibitors of nitric oxide, the role of erythropoietin, vascular changes as a basis of systolic hypertension, cardiovascular changes in hemodialysis hypertension, sources of error in the measurement of BP in hemodialysis patients, the assessment of interdialytic BP in hemodialysis patients, factors that modify the relationship between BP and mortality, the role of increased frequency and duration of dialysis, and the benefits of treating hypertension. The author calls for immediate quality control and improvement programs to more accurately monitor BP in hemodialysis patients. 6 figures. 204 references.

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