Rein et HTA chez le patient diabétique de type 2 : stratégies thérapeutiques

Renal dysfunction may occur in 20 to 30 % of patients with type 2 diabetes mellitus. Screening is essential to reduce the incidence of renal function deterioration. Adequate management includes control of arterial pressure (<130/80 mmHg), frequent assessment of serum creatinine and urinary albumin excretion. In most cases, casual blood pressure measurement is enough to start antihypertensive medications ; however, ambulatory blood pressure measurement may be useful, and detect dysautonomia, and diurnal and nocturnal uncontrolled hypertension. Blockade of the renin-angiotensin system with angiotensinconverting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) is required in all type 2 patients with diabetes mellitus and renal dysfunction (micro-albuminuria and/ or elevated serum creatinine). Maximal doses of theses medications must be used since reduction of proteinuria may be dose-dependent, ie proteinuria may diminish with increasing doses of ACEI or ARB even when blood pressure does not fall. In patients with chronic renal disease, nephrologist referral is necessary to assess therapeutic options and refine renal prognosis : long-term follow-up is usual in advanced renal failure. In those patients, pre-emptive renal transplantation usually ensures a better quality of life and survival as compared to dialysis, and should be the treatment of choice when it is possible.