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SAMJ: South African Medical Journal

On-line version ISSN 2078-5135
Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.112 n.5 Pretoria May. 2022 



Renoprotection in hypertension and diabetes - management problems lie ahead



To the Editor: The article 'Underdiagnosis of hypertension and diabetes mellitus in South Africa' in the January SAMJ[1] sheds light on two areas of great concern. Firstly, the conditions are underdiagnosed - a well-known fact. The second, however, is a problem of greater concern than underdiagnosis.

There is ample evidence in the literature (from as early as 2012) that inhibition of the renin-angiotensin system causes concentric hypertrophy of renal arterioles.[2-7] As stated by Sequeira-Lopez and Gomez,[3] proof of vascular damage in humans has been well shown, but the course of renal dysfunction (i.e. in patients with or without kidney disease) with hypertension and type 2 diabetes mellitus has not been adequately studied.

Do we just stop using the renoprotective angiotensin-converting enzyme inhibitors in all patients (especially hypertensives and diabetics) and use a combination, i.e. angiotensin II receptor blockers (such as telmisartan),[5] a beta-blocker and a diuretic (not thiazide but indapamide)? I think not. However, there is a huge potential in South Africa (SA) to study these effects. Could they be genetically heterogeneous and not be so important in some population groups? This all should, could and can be studied in SA.

In conclusion, this letter is to make doctors aware of this concept - as well as to plan a way forward.

A M Meyers

Emeritus Professor of Medicine, Division of Nephrology, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Chairperson, National Kidney Foundation of South Africa



1. Kamerman B. Underdiagnosis of hypertension and diabetes mellitus in South Africa. S Afr Med J 2022;112(1):53-60.        [ Links ]

2. Watanabe H, Martini AG, Brown EA, et al. Inhibition of the renin-angiotensin system causes concentric hypertrophy of renal arterioles in mice and humans. JCI Insight 2021;6(24):e154337. https://doiorg/10.1172/jci.insight.154337        [ Links ]

3. Sequeira-Lopez MLS, Gomez RA. Renin cells, the kidney, and hypertension. Circ Res 2021;128(7):887-907.        [ Links ]

4. Nagai Y, Yamabe F, Sasaki Y, et al. A study of morphological changes in renal afferent arterioles induced by angiotensin II type 1 receptor blockers in hypertensive patients. Kidney Blood Press Res 2020;45(2):194-208.        [ Links ]

5. Mann JFE, Schmieder RE, McQueen M, et al. Renal outcomes with telmisartan, ramipril, or both, in people at high vascular risk (the ONTARGET study): A multicentre, randomised, double-blind, controlled trial. Lancet 2008;372(9638):547-553.        [ Links ]

6. Parving HH, Brenner BM, McMurray JJV, et al. Cardiorenal end points in a trial of aliskiren for type 2 diabetes. N Engl J Med 2012;367(23):2204-2213.        [ Links ]

7. Fernandez-Fernandez B, Ortiz A, Gomez-Guerrero C, Barat A, Martín-Cleary C, Egido J. Juxtaglomerular apparatus hyperplasia under dual angiotensin blockade: A footprint of adequate RAS inhibition or a concern for renal fibrosis? BMC Nephrol 2012;13:21.        [ Links ]

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