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I read with interest and some bewilderment the recent post hoc analysis of the Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan (RENAAL) study.¹ The report concluded that baseline blood pressure (BP), especially systolic blood pressure (SBP), was a strong predictor of renal outcomes and that those with the highest baseline pulse pressure (PP) had the highest risk for nephropathy progression.¹

First, there is the question whether higher entry BP is an epiphenomenon. The prevalence of hypertension in adults with type 2 diabetes mellitus increases with increasing albuminuria.² A higher BP generally implies worse associated risk factors for cardiovascular and coronary artery disease,² which may not be completely accounted for in multivariate analysis. Therefore, such patients may end up with worse outcomes anyway.

Second, is it possible that patients with higher initial BPs in the RENAAL study¹ failed to achieve adequate BP reductions? Multivariate analysis did not . . . [Full Text of this Article]

Macaulay A. C. Onuigbo, MD, MSc
Eau Claire, Wis