New research suggests that a common second-line blood pressure treatment may not be as kidney-friendly as previously assumed for some people with diabetic kidney disease.
Blood pressure control is one of the most important ways to slow kidney damage in people with type 2 diabetes. But new research suggests that one of the most commonly prescribed groups of blood pressure medications may not offer the same level of kidney protection as other options, even when patients are already receiving today’s leading kidney-saving therapies.
The findings, presented at the 63rd ERA Congress, raise questions about a drug class used by millions of people worldwide and suggest that the choice of blood pressure medication may matter more than previously thought for patients with diabetic kidney disease (DKD).
DKD is among the leading causes of kidney failure globally. The condition develops when prolonged exposure to high blood sugar damages the tiny blood vessels that filter waste from the blood. Over time, this damage can progress to kidney failure, requiring dialysis or transplantation. Because high blood pressure places additional strain on already vulnerable kidneys, managing it has long been a central part of treatment.
In recent years, care for DKD has improved dramatically thanks to two major classes of medications. Renin-angiotensin system (RAS) inhibitors help reduce pressure inside the kidneys’ filtering units, while sodium-glucose cotransporter-2 (SGLT2) inhibitors have emerged as powerful kidney-protective drugs that can slow disease progression and reduce the risk of kidney failure. Together, these therapies are now considered foundational treatment for many patients.
Yet despite these advances, many patients still require additional medications to control blood pressure. One of the most frequently prescribed options is a group of drugs known as dihydropyridine calcium-channel blockers (DCCBs), which lower blood pressure by relaxing blood vessels.
Analysis of More Than 31,000 Patients
The study examined data from 31,031 adults with T2D between 2016 and 2021. Every participant was being treated with both RAS inhibitors and SGLT2 inhibitors.
Of those patients, 12,172 (39.2%) were also taking DCCBs, while 18,859 (60.8%) were using other blood pressure medications. Participants were followed for a median of about 3.5 years.
After accounting for differences in clinical and demographic factors, the researchers found that DCCB use was associated with a 33% greater risk of a major adverse kidney event (HR 1.33, 95% CI 1.03-1.73). These events included either a decline of at least 40% in estimated glomerular filtration rate (eGFR), a key measure of kidney function, or progression to end-stage kidney disease requiring dialysis or a kidney transplant.
“DCCBs are widely used as second-line blood pressure treatments in patients with DKD,” said Dr. Timna Agur, lead author of the study. “Our findings raise important questions about whether these medications are always the best option for patients already receiving modern kidney-protective therapies.”
Why Might DCCBs Affect Kidney Outcomes?
The researchers believe the results may be related to how DCCBs influence blood flow inside the kidneys. In people with DKD, the kidneys are often already under increased pressure because of hyperfiltration, a condition in which the filtering units are working harder than normal.
According to the researchers, DCCBs may primarily relax the blood vessels that carry blood into these filtering units while having less effect on the vessels that carry blood away. This could increase pressure within the filters themselves and potentially contribute to ongoing kidney damage.
“We initially thought the kidney-protective effects of SGLT2 inhibitors might counterbalance the potential harms associated with DCCBs,” said Dr. Agur. “However, the increased risk of kidney disease progression appeared to persist even in this group.”
The authors emphasized that the study was observational and does not prove that DCCBs directly cause worsening kidney disease. Even so, they say the findings are important because these medications are widely prescribed for patients with DKD.
“Further prospective studies and randomized controlled trials are needed to confirm these observations and better define the safest blood pressure treatment strategies for patients with DKD,” concluded Dr. Agur. “However, given how commonly these medications are prescribed, any increase in kidney risk could have important implications for large numbers of patients with DKD.”
Meeting: 63rd ERA Congress
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