Influence of HbA1c on short-term blood pressure variability in type 2 diabetic patients with diabetic nephropathy

The aim of this study was to understand the characteristics of blood pressure(BP)variability in subjects with diabetic nephropathy(DN),and identify the probable predictors affecting BP variability.Fifty-one chronic kidney disease(CKD)-hypertensive patients without diabetes(NDN group)and sixty type 2 diabetic patients with overt DN(DN group)were enrolled in this study.The values of short-term BP variability were obtained from 24 h ambulatory BP monitoring(ABPM).Variance analysis or nonparametric analysis revealed that 24-h systolic BP variability and nighttime systolic BP variability of the DN group were significantly higher than those of the NDN group[(12.23±3.66)vs.(10.74±3.83)mmHg,P<0.05;(11.23±4.82)vs.(9.48±3.69)mmHg,P<0.05].Then the patients of the DN group were divided into two groups according to glycated hemoglobin(HbA1c)level:Group A(HbA1c<7%)and Group B(HbA1c≥7%),and the t-test showed that patients in Group B had larger 24-h diastolic,daytime diastolic,and nighttime systolic/diastolic BP variability compared with Group A.In the DN group,partial correlation analysis revealed that HbA1c exhibited a strong association with 24-h diastolic,daytime diastolic,nighttime systolic and diastolic BP variability(P<0.001,P<0.001,P<0.05,and P<0.001,respectively).Taken together,larger short-term BP variability was detected in hypertensive type 2 diabetic patients with overt nephropathy and renal insufficiency.It may imply that the optimal BP variability level could benefit from a better glycaemic control.

Dual Blockade of the Renin-angiotensin-aldosterone System in Type 2 Diabetic Kidney Disease

Objective： To examine the efficacy and safety of dual blockade of the renin-angiotensin-aldosterone system （RAAS） among patients with type 2 diabetic kidney disease. Data Sources： We searched the major literature repositories, including the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE, for randomized clinical trials published between January 1990 and October 2015 that compared the efficacy and safety of the use of dual blockade of the RAAS versus the use ofmonothempy, without applying any language restrictions. Keywords for the searches included ＂＇diabetic nephropathy,＂ ＂chronic kidney disease,＂ ＂chronic renal insufficiency,＂ ＂diabetes mellitus,＂ ＂dual therapy,＂ ＂combined therapy,＂ ＂dual blockade,＂ ＂renin-angiotensin system,＂ ＂angiotensin-converting enzyme inhibitor,＂ ＂angiotensin-receptor blocker,＂ ＂aldosterone blockade,＂ ＂selective aldosterone blockade,＂ ＂renin inhibitor,＂ ＂direct renin inhibitor,＂ ＂mineralocorticoid receptor blocker,＂ etc. Study Selection： The selected articles were carefully reviewed. We excluded randomized clinical trials in which the kidney damage of patients was related to diseases other than diabetes mellitus. Results： Combination treatment with an angiotensin-converting enzyme inhibitor supplemented by an angiotensin I I receptor blocking agent is expected to provide a more complete blockade of the RAAS and a better control of hypertension. However, existing literature has presented mixed results, in particular, related to patient safety. In view of this, we conducted a comprehensive literature review in order to explain the rationale for dual blockade of the RAAS, and to discuss the pros and cons. Conclusions： Despite the negative results of some recent large-scale studies, it may be immature to declare that the dual blockade is a failure because of the complex nature of the RAAS surrounding its diversified functions and utility. Further trials are warranted to study the combination therapy as an evidence-based practice.