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Letters to the Editor

In reply: Is diabetes still a compelling indication for renin-angiotensin-aldosterone system inhibitors?

Sunil Bhandari, MBChB, FRCP, PhD, M Clin Edu, FHEA, Tasnim Momoniat, MBChB, MRCP (UK) and Duha Ilyas, MBBS, MRCP (UK)
Cleveland Clinic Journal of Medicine January 2020, 87 (1) 9-10; DOI: https://doi.org/10.3949/ccjm.87c.01002
Sunil Bhandari
Hull University Teaching Hospitals, United Kingdom
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Tasnim Momoniat
Hull University Teaching Hospitals, United Kingdom
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Duha Ilyas
Hull University Teaching Hospitals, United Kingdom
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We would like to thank Dr. Fakheri and colleagues for their extremely helpful comments on our recent review of angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs).1

We agree entirely with their suggestion on the lack of current data on any superiority of ACE inhibitors or ARBs in patients with diabetes without proteinuria and diabetes with “normal” renal function.2,3 As mentioned, the sentence perhaps lacks clarity.

In the United Kingdom, ACE inhibitors and ARBs are commonly prescribed for diabetic microalbuminuria, proteinuric renal disease, and hypertension, as well as after myocardial infarction and in heart failure.4 We therefore also concur that heart failure with reduced ejection fraction could be added to the list of conditions that are indications for inhibition of the renin-angiotensin-aldosterone system irrespective of the initial blood pressure level.

Interestingly, chronic kidney disease is associated with significantly increased risk of cardiovascular disease and cardiovascular death.5,6 Studies of patients with chronic kidney disease have noted an increased relative risk of coronary heart disease, heart failure, and stroke compared with those without chronic kidney disease.7,8 We recognize that additional randomized controlled studies and a better understanding of these differences in risk are required to guide optimal therapy and improve outcomes, and we wonder if ACE inhibitors and ARBs might be useful in this high-risk population even before proteinuria is established, as alluded in the heart failure group.

Finally, although the data are not available, we wonder if over a longer period of follow-up, one may in the future see a benefit from reduced intraglomerular hyperfiltration, but we concede this is mere speculation, and more recent data have challenged the hyperfiltration model of renal damage.

  • Copyright © 2020 The Cleveland Clinic Foundation. All Rights Reserved.

REFERENCES

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    1. Momoniat T,
    2. Ilyas D,
    3. Bhandari S
    . ACE inhibitors and ARBs: managing potassium and renal function. Cleve Clin J Med 2019; 86(9):601–607. doi:10.3949/ccjm.86a.18024
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    1. Palmer SC,
    2. Mavridis D,
    3. Navarese E,
    4. et al
    . Comparative efficacy and safety of blood pressure lowering agents in adults with diabetes and kidney disease: a network meta-analysis. Lancet 2015; 385(9982):2047–2056. doi:10.1016/S0140-6736(14)62459-4
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    1. Bangalore S,
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    . Diabetes mellitus as a compelling indication for use of renin angiotensin system blockers: systematic review and meta-analysis of randomized trials. BMJ 2016; 352:i438 doi:10.1136/bmj.i438.
    OpenUrlAbstract/FREE Full Text
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    1. NICE guidelines (CG127)
    . Hypertension in adults: diagnosis and management. Available at: http://www.nice.org.uk/guidance/cg127/chapter/1-recommendations#choosingantihypertensive-drug-treatment-2. Accessed on October 18th, 2019.
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    1. Go AS,
    2. Chertow GM,
    3. Fan D,
    4. McCulloch CE,
    5. Hsu CY
    . Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004; 351(13):1296–1305. doi:10.1056/NEJMoa041031
    OpenUrlCrossRefPubMed
  6. ↵
    1. Weiner DE,
    2. Tighiouart H,
    3. Amin MG,
    4. et al
    . Chronic kidney disease as a risk factor for cardiovascular disease and all-cause mortality: a pooled analysis of community-based studies. J Am Soc Nephrol 2004; 15(5):1307–1315. doi:10.1097/01.asn.0000123691.46138.e2
    OpenUrlAbstract/FREE Full Text
  7. ↵
    1. Meisinger C,
    2. Doring A,
    3. Lowel H,
    4. KORA Study Group
    . Chronic kidney disease and risk of incident myocardial infarction and all-cause and cardiovascular disease mortality in middle-aged men and women from the general population. Eur Heart J 2006; 27:1245–1250. doi:10.1093/eurheartj/ehi880
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    1. Muntner P,
    2. Judd SE,
    3. McClellan W,
    4. et al
    . Incidence of stroke symptoms among adults with chronic kidney disease: results from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Nephrol Dial Transplant 2012; 27(1):166–173. doi:10.1093/ndt/gfr218
    OpenUrlCrossRefPubMed
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Cleveland Clinic Journal of Medicine: 87 (1)
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1 Jan 2020
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In reply: Is diabetes still a compelling indication for renin-angiotensin-aldosterone system inhibitors?
Sunil Bhandari, Tasnim Momoniat, Duha Ilyas
Cleveland Clinic Journal of Medicine Jan 2020, 87 (1) 9-10; DOI: 10.3949/ccjm.87c.01002

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In reply: Is diabetes still a compelling indication for renin-angiotensin-aldosterone system inhibitors?
Sunil Bhandari, Tasnim Momoniat, Duha Ilyas
Cleveland Clinic Journal of Medicine Jan 2020, 87 (1) 9-10; DOI: 10.3949/ccjm.87c.01002
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