Calcium antagonists and renal disease

Identifying Clinical and Genomic Features Associated With Chronic Kidney Disease

We apply a pattern-based classification method to identify clinical and genomic features associated with the progression of Chronic Kidney disease (CKD). We analyze the African-American Study of Chronic Kidney disease with Hypertension dataset and construct a decision-tree classification model, consisting 15 combinatorial patterns of clinical features and single nucleotide polymorphisms (SNPs), seven of which are associated with slow progression and eight with rapid progression of renal disease among African-American Study of Chronic Kidney patients. We identify four clinical features and two SNPs that can accurately predict CKD progression. Clinical and genomic features identified in our experiments may be used in a future study to develop new therapeutic interventions for CKD patients.

Que nous apprennent les grands essais cliniques de prévention cardiovasculaire et rénale chez le malade diabétique de type 2 hypertendu ?

Type 2 diabetes mellitus and hypertension are frequently associated. Cardiovascular morbidity is a major burden in these patients. Furthermore a renal disease appears in 40% of them that may lead to chronic terminal renal failure. Whatever the stage of the renal disease, it increases the cardiovascular risk. A majority of type 2 diabetic patients will eventually died of cardiovascular complications before having reached chronic terminal renal failure. Many large clinical trials including type 2 diabetic patients with hypertension have been performed in the last 20 years with cardiovascular morbidity and mortality as primary outcomes. These trials mainly evaluated the role of glycemic control, of hypertension as well as the decrease of LDL-cholesterol. Based on these trials, the prescription type of hypertensive type 2 diabetic patient should include, besides hygienic and dietary advices, antidiabetic treatment, thiazide and/or betablocker and platelet inhibitor. Statin should be prescribed for secondary prevention if serum LDL-cholesterol is above 1,3 g/l and for primary prevention depending on serum LDL-cholesterol and on the number of cardiovascular risk factors. The objectives are an HbA1c below 6,5%, a LDL-cholesterol below 1g/l and a blood pressure below 150/80 mmHg. The appearance of diabetic nephropathy alters the treatment and the therapeutic objectives. Many large trials aimed at preventing microalbuminuria (primary prevention), macroproteinuria (secondary prevention), and chronic renal failure (tertiary prevention) have been conducted. For primary prevention, angiotensin-converting-enzyme inhibitors should be prescribed in case of hypertension because they delay the appearance of microalbuminuria. For secondary prevention, angiotensin-converting-enzyme inhibitors and angiotensin-receptor blockers decrease albuminuria excretion rate and delay the appearance of macroproteinuria whatever the blood pressure. Tertiary prevention is based on angiotensin-receptor blockers since they slow down the decrease of renal function. The objectives are a blood pressure below 130/80 mmHg and the regression or the reduction of albuminuria excretion rate. Intensified and target-driven interventions aimed at multiple risk factors implicated in cardiovascular and renal lesions, as successfully performed in the STENO-2 study, reduce the risk of cardiovascular and renal morbidity and mortality. In this article, large clinical trials having the prevention of cardiovascular and renal risks as primary outcomes were analyzed.

A Prospective Open-Label Randomised Trial of Quinapril and/or Amlodipine in Progressive Non-Diabetic Renal Failure

BACKGROUND

Treatment of hypertension slows the progression of non-diabetic nephropathies, but the optimal regimen is unknown. Angiotensin-converting enzyme inhibitors are more effective than beta-blockers, but their merits relative to calcium channel blockers are less clear.

METHODS

73 hypertensive patients with progressive non-diabetic nephropathies were prospectively randomised to open-label quinapril (Q, n = 28), amlodipine (A, n = 28) or both drugs (Q&A, n = 17). Therapy was increased to achieve a diastolic blood pressure < 90 mm Hg. Patients were followed for 4 years or until death. The primary outcome was the combined endpoint of doubling serum creatinine, starting renal replacement therapy or death.

RESULTS

There was no significant difference in the primary outcome, or in the change of glomerular filtration rate. Blood pressure was equally controlled throughout the study period. 29 (40%) patients were withdrawn from the allocated therapy (Q 39%, A 36%, Q&A 47%). Because of the large crossover between trial arms, the data were re-analysed per protocol. The effect on preventing the need for renal replacement therapy then approached significance between the groups (p = 0.089) and the combined quinapril-containing groups were less likely than the amlodipine group to achieve the primary endpoint (p = 0.038), or the individual endpoints of renal replacement therapy (p = 0.030) or doubling creatinine (p = 0.051).

CONCLUSIONS

Quinapril is more effective than amlodipine at reducing the incidence of dialysis in patients with progressive renal failure, but only if they can tolerate the drug. The tolerability of these drugs in patients with advanced renal failure is poor.

Update on calcium antagonists and the kidney

PURPOSE OF REVIEW

The treatment of hypertension has been proven to reduce cardiovascular and renal risk. The role of long-acting calcium channel antagonists in the management of hypertension has been confused in the past because of a lack of controlled clinical trials on people with hypertension and in subpopulations including those with diabetes and renal disease. The year 2002 saw the publication of the results of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, the largest ever prospective drug-treatment trial, which involved 33 357 people with hypertension and included a calcium-antagonist group of 9048 individuals. Major publications on blood pressure control in people with kidney disease include the African American Study of Kidney Disease and Hypertension, and publications on people with diabetes include the results of the normotensive arm of the Appropriate Blood Pressure Control in Diabetes trial.

RECENT FINDINGS

The main finding, from the studies reported in the last year, is that blood pressure control can be achieved using one or more of the first-line agents, including diuretics, calcium antagonists and angiotensin-converting enzyme inhibitors. On the basis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, diuretics make clinical and economic sense as initial therapy for those with hypertension. Calcium antagonists are well tolerated and effective and should be considered as the initial drug therapy when diuretics are not tolerated or when multiple drug therapy is indicated. Angiotensin-converting enzyme inhibitors should be used in people with nephropathy, and, in these patients, will nearly always need to be part of multiple drug therapy to achieve blood pressure control. When blood pressure control can be achieved in largely non-nephropathic populations, there is further evidence that the drug class used as initial therapy may not be important. One of the main themes coming from the literature in the last year is that renal function is increasingly being recognized as an important outcome measure and marker of cardiovascular risk.

SUMMARY

The focus in blood pressure management must now be on identifying those with hypertension and bringing their blood pressure to target. For the majority of those with hypertension and renal disease, multiple drug therapy will be required, and, to achieve blood pressure targets, calcium antagonists are an appropriate part of this regimen. Particular attention is needed for nephropathic patients because of their higher risk of progression and the need for combination therapy; this group is likely to be the focus of future research and publications.

Treatment of hypertension in renal transplant recipients

PURPOSE OF REVIEW

Hypertension is very common in renal transplant recipients and is a significant risk factor for mortality from cardiovascular diseases and for development of graft dysfunction.

RECENT FINDINGS

Recent guidelines for the treatment of hypertension (Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure VI Report and World Health Organization Guidelines) do not directly address post-transplant hypertension. Specific recommendations for the drug treatment of hypertension in renal allograft recipients have not been given in the Clinical Practice Guidelines of the American Society of Transplantation or those of the European Renal Association.

SUMMARY

The present paper summarizes some important aspects of post-transplant hypertension and discusses potential treatment strategies aimed at reducing blood pressure and thus improving patient and allograft survival.

Lacidipine inhibits adhesion molecule and oxidase expression independent of blood pressure reduction in angiotensin-induced vascular injury

Dihydropyridines can inhibit gene expression in-vitro and may have a protective vascular effect independent of blood pressure reduction. We tested the hypothesis that lacidipine prevents induction of inducible NO synthase (iNOS), influences leukocyte adhesion and infiltration, inhibits nuclear factor (NF)-kappaB transcription factor activity, and ameliorates end-organ damage in a transgenic rat model of angiotensin (Ang) II--dependent organ sclerosis. We treated rats transgenic for human renin and angiotensinogen (dTGR) from week 4 to 7 with lacidipine (0.3 or 3 mg/kg by gavage). Blood pressure was measured by tail cuff. Organ damage was assessed by histology and immunohistochemistry. Adhesion molecules and cytokines were analyzed by immunohistochemistry. Transcription factors were analyzed by mobility shift assays. Untreated dTGR developed moderate hypertension, cardiac hypertrophy, and severe renal damage with albuminuria. Lacidipine decreased blood pressure slightly at the low dose and substantially at the higher dose. However, both treatments reduced albuminuria and plasma creatinine to the same degree (P<0.05). Intercellular adhesion molecule-1 (ICAM-1) was markedly reduced by lacidipine as well as renal neutrophil and monocyte infiltration. Lacidipine reduced mitogen-activated protein (MAP) kinase phosphorylation and iNOS expression in both cortex and medulla. NF-kappaB and AP-1 were activated in dTGR but reduced by lacidipine. Lacidipine ameliorates Ang II-induced end-organ damage independent of blood pressure lowering, perhaps by inhibiting the MAP kinase pathway and NF-kappaB activation.

Comparison of L-type and mixed L- and T-type calcium channel blockers on kidney injury caused by deoxycorticosterone-salt hypertension in rats

The efficiency of calcium channel blockers (CCBs) in the treatment of chronic renal disease (CRD) is controversial. In this study, we investigated whether combined T- and L-type CCBs, using mibefradil (30 mg/kg/d), provided superior protection versus traditional L-type voltage-gated CCBs, using amlodipine (10 mg/kg/d), in the deoxycorticosterone acetate (DOCA)-salt model of high glomerular blood pressure (P(GC)) and rapidly developing kidney damage. After 4 to 5 weeks of DOCA-salt, amlodipine did not reduce proteinuria (protein, 341 +/- 90 versus 482 +/- 54 mg/24 h; P = not significant) or degree of glomerular damage (20% +/- 4% versus 28% +/- 6% damaged glomeruli; P = not significant) compared with untreated rats. Conversely, mibefradil reduced proteinuria and glomerular damage versus untreated DOCA-salt rats (protein, 244 +/- 75 mg/24 h; P < 0.02; damaged glomeruli, 11% +/- 3%; P < 0.05). Both CCBs had similar antihypertensive actions, returning blood pressure to the untreated sham value. Of note, P(GC) also was reduced by a similar extent (and to the sham value) with both mibefradil (58 +/- 2 mm Hg; P < 0.001) and amlodipine (61 +/- 2 mm Hg; P < 0.005) versus untreated DOCA-salt rats (70 +/- 1 mm Hg). This study shows that combined T- and L-type CCBs provide superior protection against CRD in the DOCA-salt model compared with L-type CCBs alone. However, this protection was not hemodynamic because similar systemic and glomerular antihypertensive responses occurred with both mibefradil and amlodipine. Although mibefradil was withdrawn from the market because of adverse drug interactions not associated with CCBs, other mixed channel blockers may provide an alternative or adjunctive therapy to angiotensin-converting enzyme inhibition in CRD.

The effects of an ACE inhibitor and a calcium antagonist on the progression of renal disease: the Nephros Study

BACKGROUND

The renoprotective effect of ACE inhibition in chronic renal disease is well established but the studies on effects of calcium antagonists on progression of renal disease and on proteinuria have given varying results.

METHODS

We conducted an open long-term randomized prospective multi-centre study comparing the combination of ramipril and felodipine ER (F) with either drug alone in non-diabetic renal disease. Included were patients with uncontrolled hypertension (diastolic blood pressure (DBP)) > or =95 mmHg on treatment with a diuretic and a beta-blocker. Fifty-one patients received the combination of R and F, 54 patients R, and 53 patients F. The treatment goal was a DBP <90 mmHg and a similar BP reduction in the three groups. Mean doses at the last visit were 5+5, 10 and 9 mg, respectively, after a mean treatment time of nearly 2 years. The progression of renal impairment was studied by serial measurements of serum creatinine, iohexol clearance, and albuminuria.

RESULTS

The reduction in supine systolic (S) BP and DBP expressed as median values were -19.0/-14.5,-14.3/-15.0 and -13.5/-13.3 mmHg in the R+F, R, and F groups, respectively. There was no significant difference between the groups. When correction for the acute drug effect was performed the R+F group had a slower progression rate of the renal disease (loss of glomerular filtration rate (GFR) ml/min/year) compared with the F group (P<0.05) but not to the R group (P>0.20). There was a rise in albuminuria after 2 years in the F group (P<0.05), but no significant change was found in the other groups.

CONCLUSIONS

In patients with non-diabetic renal disease the combination of an ACE inhibitor and a calcium antagonist in reduced doses used in addition to baseline therapy with beta-blockers and diuretics, tended to cause a better BP reduction as each drug per se. The R+F treatment also caused a slower progression of the renal disease compared with F alone. The combination treatment seems to afford better BP control and appears to be a favourable therapeutic option in patients with renal disease and hypertension.

Early glomerular dysfunction in human renal allografts

BACKGROUND

The long-term outcome of renal allografts is characterized by a progressive deterioration of renal function and graft loss. Our aim was to determine early glomerular functional abnormalities, before they become clinically apparent.

METHODS

Glomerular hemodynamics and dextran sieving were characterized in 21 well-functioning cadaveric renal allograft recipients [normal glomerular filtration rate (GFR) and albumin excretion rate (AER), who also had a kidney biopsy with normal or minimal histological changes] and in 15 uninephrectomized kidney donors. Both groups were one to three years after transplantation or uninephrectomy.

RESULTS

The GFR and renal plasma flow (RPF) were similar in both groups (62 +/- 3 vs. 63 +/- 4, and 343 +/- 26 vs. 334 +/- 21 mL/min/1.73 m2 for GFR and RPF, in cadaveric recipients vs. donors, respectively), the AER was normal in both groups, but the mean arterial pressure was higher in renal recipients (103 +/- 3 vs. 94 +/- 3 mm Hg in uninephrectomy controls, P < 0.05). Despite similar levels of overall glomerular function in the two groups, the dextran sieving curve was uniformly elevated in the renal allograft recipients versus uninephrectomy controls (P < 0.05 for dextrans 38 to 66 A). Using a log-normal glomerular pore-size distribution model to analyze potential mechanisms, the elevation in the dextran sieving curve resulted from a shift in the distribution of glomerular filtering pores to a larger size (mean glomerular pore size 46 +/- 2 vs. 43 +/- 2 A for uninephrectomy controls, P < 0.05), resulting in a larger fraction of filtrate volume permeating very large pores. By morphometric analysis, the thickness of the glomerular basement membrane was increased in kidney allograft as compared to 2-kidney biopsy controls (614 +/- 33 vs. 427 +/- 22 nm, respectively, P < 0.05).

CONCLUSIONS

Even in "well functioning" renal allografts there is a glomerular dysfunction characterized by increased permeability to macromolecules resulting from a shift of the glomerular pores to a larger size. These changes could be mediated by ultrastructural alterations at the glomerular capillary or by alterations in intraglomerular hemodynamics. Early allograft dysfunction may contribute to the progressive renal insufficiency of renal allografts.

Follow-up of renal function in treated and untreated older patients with isolated systolic hypertension. Systolic Hypertension in Europe (Syst-Eur) Trial Investigators

BACKGROUND

In the outcome trials that provided information on renal function in older hypertensive patients, diuretics and beta-blockers were mostly used as first-line drugs. The long-term renal effects of calcium-channel blockers remain unclear.

OBJECTIVE

To compare the changes in renal function in 2,258 treated and 2,148 untreated patients with isolated systolic hypertension, of whom 455 had diabetes mellitus and 390 had proteinuria.

METHODS

We performed a post-hoc analysis of the double-blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) Trial. Active treatment was initiated with nitrendipine (10-40 mg/day) with the possible addition of enalapril (5-20 mg/day), hydrochlorothiazide (12.5-25 mg/day), or both, titrated or combined to reduce the sitting systolic blood pressure by at least 20 mmHg, to less than 150 mmHg. The main outcome measures were serum creatinine concentration and creatinine clearance calculated by the formula of Cockroft and Gault.

RESULTS

Serum creatinine concentration at the time when participants were randomly allocated to study groups was less than 176.8 micromol/l (2.0 mg/dl), averaging 88 micromol/l. At the time of the last serum creatinine measurement, the blood pressure difference (P< 0.001) between the two groups was 11.6/4.1 mmHg. In the intention-to-treat analysis (11,427 patient-years), serum creatinine and the calculated creatinine clearance were not influenced by active treatment. However, in the patients assigned randomly to receive active treatment, the incidence of mild renal dysfunction (serum creatinine at least 176.8 mmol/l) decreased by 64% (P= 0.04) and that of proteinuria by 33% (P= 0.03). Active treatment reduced the risk of proteinuria more in diabetic than in non-diabetic patients: by 71%, compared with 20% (P= 0.04). In non-proteinuric patients, active treatment did not influence serum creatinine, whereas in patients with proteinuria at entry to the study, serum creatinine decreased on active treatment (P< 0.001). Furthermore, in on-randomized treatment comparison stratified for risk at baseline, serum creatinine concentration did not change (P= 0.98) in patients continuing to receive monotherapy with nitrendipine, whereas it increased by 6.73 mmol/l (P < 0.001) in patients who received hydrochlorothiazide alone or in combination with other study medication (P < 0.001 for difference in trends).

CONCLUSIONS

In older patients with isolated systolic hypertension, antihypertensive treatment starting with the dihydropyridine calcium-channel blocker, nitrendipine, did not decrease blood pressure at the expense of renal function and prevented the development of proteinuria, especially in diabetic patients.

Amlodipine is comparable to angiotensin-converting enzyme inhibitor for long-term renoprotection in hypertensive patients with renal dysfunction: a one-year, prospective, randomized study

Unlike angiotensin converting enzyme inhibitors (ACEI), few long-term studies have shown calcium antagonists to retard the progression of renal dysfunction. Our aim was to prospectively compare the effects of amlodipine and ACEI (enalapril) on renal function in hypertensive patients with renal impairment due to chronic glomerulonephritis and essential hypertension. A total of 72 hypertensive patients with serum creatinine (Cr) > 1.5 mg/dL were randomly allocated to treatment with either drug. During a 1-year period, 33% of the patients treated with ACEI dropped out due to adverse events, whereas 9% of patients with amlodipine dropped out. Data of 28 patients were available for analysis of more than 1-year follow-up. Reductions in blood pressure were comparable between the amlodipine (from 165/101 to 138/81 mm Hg) and ACEI groups. Serum Cr increased from 2.1+/-0.8 (SD) to 2.6+/-1.0 mg/dL with amlodipine (n = 16), but the difference was equivalent to that with ACEI (n = 12). Creatinine clearance (Ccr) in the moderate dysfunction group (basal Cr, 1.5 to 2.0 mg/dL) changed from 36+/-10 to 33+/-11 mL/min (not significant) with amlodipine, and the change was similar to that noted with ACEI. Annual declines in Ccr with amlodipine (-3.7 mL/min/year) and ACEI (-2.6 mL/min/year) were comparable, and both tended to be smaller than the annual decline in glomerular filtration rate reported in the Modification of Diet in Renal Disease study (-6 mL/min/year). Serum potassium was increased significantly (P < .01), from 4.5+/-0.4 to 5.3+/-0.8 mEq/L, only in the ACEI group. This 1-year prospective study demonstrated the effect of amlodipine on renal function to be likely the same as that of ACEI. Furthermore, amlodipine was better tolerated than ACEI for hypertensive patients with renal dysfunction.

Influence of the timing of initiating antihypertensive therapy in hypertensive rats with renal failure

The important contribution of hypertension to the progression of renal failure is well realized. However, it have been less discussed which drugs are suitable for the different stages of progressive renal failure. The present study examined the effects of timing of antihypertensive therapy using calcium channel blocker and angiotensin converting enzyme inhibitor in 5/6 nephrectomized spontaneously hypertensive rats (SHRs). Forty male 6 week old SHRs were divided into 5 groups (n=8 in each group), and they were placed on a high salt diet after 5/6 nephrectomy. Group 1, high salt diet without any drug. Group 2 received 0.2 mg/kg/day of amlodipine and group 3 received 0.2 mg/kg/day of enalapril mixed in the high salt diet from week 6 respectively. Similarly group 4 received the same doses of amlodipine, and group 5 received the same doses of enalapril from week 10. Each drug protected from increasing blood pressure in 4 groups, and no significant difference was observed between the effects of amlodipine and enalapril. Proteinuria was reduced with both drugs. In histopathological evaluation, glomerulosclerosis was controlled only in group 2, and arterio/olosclerosis was significantly suppressed in all treated groups except group 5. From these results, both amlodipine and enalapril are renal protective in early stage of renal failure with hypertension. However, in advanced stage of renal failure, amlodipine is superior in its renal protective effect.

Benidipine inhibits apoptosis during ischaemic acute renal failure in rats

We have investigated the effects of benidipine (hydrochloride), a calcium antagonist, against ischaemic acute renal failure in rats. Using histological examination, we studied whether the inhibition of apoptosis was associated with the protective effects of benidipine on the ischaemic renal injury. Acute renal failure was induced by the unilateral clamping of the left renal artery for 60 min, followed by reperfusion and contralateral nephrectomy. Drugs were given intravenously 5 min before the unilateral clamping. Prophylactic administrations of benidipine (10 microg kg(-1), i.v.) significantly ameliorated the development of renal failure as estimated by the measurements of serum creatinine and blood urea nitrogen 24 h after the reperfusion. Amlodipine (besilate, 100 and 300 microg kg(-1), i.v.) tended to attenuate renal dysfunction. Lisinopril (300 and 1000 microg kg(-1), i.v.), an angiotensin converting enzyme inhibitor, was ineffective in this acute renal failure model. Histological examination using the terminal transferase-mediated dUTP-biotin nick end-labelling (TUNEL) method to detect apoptotic cells revealed that the TUNEL-positive tubular epithelium was prominent in the renal cortex 24 h after the reperfusion. The TUNEL-positive cells were significantly reduced by pretreatment with benidipine. The results demonstrate that benidipine can ameliorate the ischaemic acute renal failure in rats and suggest that the renoprotective effect of benidipine was at least partly attributable to the reduction of apoptosis in tubular epithelial cells.

Hypertension after liver transplantation: a predictive role for pretreatment hemodynamics and effects of isradipine on the systemic and renal circulations

Hypertension developing after liver transplantation during immunosuppression with cyclosporine A reflects an unusual hemodynamic transition from peripheral vasodilation to systemic and renal vasoconstriction. Although dihydropyridine calcium channel blockers are often administered for their efficacy in promoting vasodilation, some liver transplant recipients report marked symptomatic intolerance to these agents. In the present study we examined systemic and renal responses to isradipine using systemic (thoracic bioimpedance) and renal hemodynamic measurements in 15 liver transplant recipients studied at the time of initial diagnosis of posttransplant hypertension and after 3 months of treatment. Circadian blood pressure patterns were examined by overnight ambulatory blood pressure monitoring before and during antihypertensive therapy. During isradipine administration, blood pressure decreased from 151 +/- 3/91 +/- 2 to 130 +/-3/81 +/- 2 mm Hg (P < .01) without change in renal blood flow (406 +/- 43 to 425 +/- 52 mL/min/1.73m2, P = NS) or renal vascular resistance index (25,674 +/-3312 to 20,520 +/- 2311 dynes x sec x cm(-5)/m2, P = NS). Pre-treatment differences in systemic vascular tone persisted during treatment and predicted the tendency for symptomatic tachycardia and flushing, predominantly in those with hyperdynamic circulations. Twice daily dosing of isradipine was associated with partial and significant restoration of the nocturnal decrease in blood pressure (systolic blood pressure decreased 5.5%, normal 13%), usually absent early after transplantation. Our results demonstrate the ability of hemodynamic measurements to predict the symptomatic response to antihypertensive therapy in the posttransplant setting.

Pharmacotherapy in congestive heart failure: reflections on diabetes, clinical trials, and cardiovascular morbidity and mortality

Hypertension and diabetes are commonly found conditions, which predispose to premature cardiovascular morbidity and mortality. A strong consensus has emerged in support of aggressive blood pressure reduction in order to forestall the almost inevitable complications that follow from being a hypertensive diabetic. As of yet though it is not clearly determined as to what represents the best class(es) of antihypertensive medications to effect such blood pressure reduction. In this regard, considerable debate has arisen as to the cost/benefit ratio of dihydropyridine calcium channel blockers in the hypertensive diabetic. Although studies such as the Fosinopril vs. Amlodipine Cardiovascular Events Trial and the Appropriate Blood Pressure Control in Diabetes study would seem to argue against the use of dihydropyridine calcium channel blockers in the diabetic hypertensive, other studies such as the subset analyses of the Syst-Eur and the Syst-China and the Hypertension Optimal Treatment study provide almost compelling evidence for the safety of low to moderate doses of a dihydropyridine calcium channel blockers in this population. Safety issues of dihydropyridine calcium channel blockers will remain unresolved until the release of the Antihypertensive and Lipid Lowering Study to Prevent Heart Attack results at which time a resolution to this question should be forthcoming. (c)2000 by CHF, Inc.

Treatment of diabetic patients with hypertension

This review attempts to highlight the potential of calcium-channel blockers in the prevention of sequelae of diabetes mellitus and hypertension in patients who have both disorders. Evidence-based medicine is driven by the results of randomized, clinical trials. Major contributions were therefore derived from post hoc analyses of the diabetic patients enrolled in placebo-controlled trials, such as Systolic Hypertension in the Elderly Program (SHEP), Systolic Hypertension in Europe (Syst-Eur), and Systolic Hypertension in China (Syst-China), and stepped-care blood-pressure-oriented trials, such as the Hypertension Optimal Treatment (HOT) and United Kingdom Prospective Diabetes Study (UKPDS). Several studies, such as the Fosiniprl; versus Amlodipine Cardiovascular Events Trial (FACET) and Appropriate Blood Pressure Control in Diabetes (ABCD) Trial, have compared the relative merits of angiotensin-converting enzyme and calcium-channel blockers in preserving renal function and metabolic balance in diabetic patients with hypertension, but their publications focused on cardiovascular disorders, which were only secondary end points. On balance, the articles reviewed prove that dihydropyridine calcium-channel blockers score particularly well in the prevention of cardiovascular complications in diabetic patients with hypertension.