Antihypertensive Treatment and Nephroprotection: Which Target to Achieve?

In patients with diabetes, nephropathy, with or without an increased urinary protein excretion, is accompanied by a much greater risk of progression toward ESRD, as well as of the occurrence of myocardial infarction, heart failure or stroke. Many randomized controlled trials (RCTs) have documented that in these patients, both progression to renal events and fatal or nonfatal CV outcomes can be favorably affected by antihypertensive drug treatment. There is no agreement; however, on how low the BP should be brought, to maximize the renal and CV protective effects of the BP-lowering intervention under this circumstance, namely, whether the target should be similar to the one recommended for the general hypertensive population, i.e., 130/80 mmHg or lower BP values should be pursued.

Patients with diabetic nephropathy and macroalbuminuria are at very high CV risk, and an optimal risk factor control in general should be the ambition, controlling not only hypertension but also hyperglycemia and hyperlipidemia, as well as avoidance of tobacco smoking. The BP goal in these patients with macroalbuminuria could be <130/80 mmHg but at the same time, many patients may have overt or subclinical ischemic heart disease and thus, risk coronary hypoperfusion, if the systolic BP level is lowered too far.

It is currently debated whether the same BP goal should be applied in patients with microalbuminuria. The lack of evidence has been taken as a reason to keep a more conservative BP goal (<140/85-90 mmHg), but some proponents would like to see an ambitious BP goal (<130/80 mmHg) in these patients. Further, evidence is needed based on randomized controlled clinical trials before this clinical dilemma can be settled. A blocker of the renin-angiotensin system is recommended to be one part of a multiple drug combination approach to control hypertension in patients with macroalbuminuria or microalbuminuria. But despite the use of existing RAAS blockers, patients often remain uncontrolled and require a potent, superior and more efficacious RAAS blocker for the treatment of hypertension. Azilsartan is the 8th ARB to be approved by US FDA for hypertension. Azilsartan has proved to play an important role in reducing the need for treatment compromise in hypertensive patients as well as patients with comorbidities.