BENEFITS AND COST OF ANTIHYPERTENSIVE TREATMENT IN INCIPIENT AND AVERT DIABETIC NEPHROPATHY

Prevalence The prevalence of abnormally elevated urinary albumin excre tion rate (>30 mg/24 h) is approximately 40% in insulin-dependent and in non-insulin-dependent diabetic patients. Diabetes has become the le ading cause of endstage renal failure in Europe, USA and Japan. Approx imately 90% of the direct and indirect costs of caring for diabetic pa tients are spent on the complications of diabetes. Risk factors Identi fication of patients at high risk of developing diabetic nephropathy i s possible by screening for microalbuminuria (30-300 mg/24 h). Additio nal risk factors/markers for development of nephropathy are male sex, genetic predisposition, ethnic conditions, early onset of diabetes, po or metabolic control, hyperfiltration, elevated prorenin and smoking. Elevated urinary albumin excretion rate indicates a substantially incr eased cardiovascular morbidity and mortality risk in diabetic patients . Prevention of nephropathy Randomized controlled trials in normotensi ve insulin-dependent and in non-insulin-dependent diabetic patients wi th persistent microalbuminuria indicate that angiotensin converting en zyme (ACE) inhibitors diminish urinary albumin excretion rate, and pos tpone and may even prevent progression to clinical overt nephropathy. These findings indicate that screening and intervention programs could probably save lives and lead to considerable economic savings. Treatm ent of nephropathy Systemic blood pressure elevation to a hypertensive level is an early and frequent phenomenon in diabetic nephropathy. Fu rthermore, nocturnal blood pressure elevation (non-dippers) occurs mor e frequently in patients with nephropathy Systemic blood pressure elev ation, hyperglycaemia, albuminuria and the D polymorphism in the ACE g ene accelerate the progression of diabetic nephropathy. Studies of the impact of other potential progression promoters (i.e. smoking, hyperl ipidaemia and protein intake) have yielded conflicting results. Effect ive blood pressure reduction using ACE inhibitors or drugs of other cl asses, or both, frequently in combination with diuretics reduces album inuria, delays the progression of nephropathy, postpones renal failure and improves survival in patients with diabetic nephropathy. Antihype rtensive treatment for diabetic nephropathy extends life and saves mon ey. (C) 1998 Rapid Science Ltd.