Evolving strategies for renoprotection: diabetic nephropathy

A cumulative incidence of diabetic nephropathy of 25-40% has been documente d after duration of diabetes of at least 25 years in both type 1 and type 2 diabetic patients. Diabetic nephropathy has become the leading cause (25-4 4%) of end-stage renal failure in Europe, the United States and Japan. Unti l the early 1980s, no renoprotective treatment was available for use in dia betic nephropathy. Death occurred on average 5-7 years after the onset of p ersistent proteinuria. It should be recalled that development of treatment modalities occurred in reverse order: in the early 1980s, antihypertensive treatment of diabetic nephropathy was introduced, and in the early 1990s, p rimary and secondary prevention with improved glycaemic control and angiote nsin-converting enzyme inhibition. The two main treatment strategies for pr imary prevention of diabetic nephropathy are improved glycaemic control and blood pressure lowering, particularly using drugs such as angiotensin-conv erting enzyme inhibitors. Megatrials and meta-analyses have clearly demonst rated the beneficial effect of both the above-mentioned treatment modalitie s. Secondary prevention, that is, treatment modalities applied to diabetic patients with high risk of development of diabetic nephropathy (e.g. those with microalbuminuria) has been documented, applying angiotensin-converting enzyme inhibitors in both type 1 and type 2 diabetic patients. Furthermore , improved metabolic control reduces the risk of progression. In special ca ses (such as pancreas transplantation) even reversal of diabetic glomerular lesions has been documented. Antihypertensive treatment of patients with o vert nephropathy induces a reduction in albuminuria, a reduction in the rat e of decline of glomerular filtration rate, delays development of end-stage renal failure and improves survival. Many potential treatment modalities i n preventing and treating diabetic nephropathy are presently being evaluate d.Curr Opin Nephrol Hypertens 10:515-522. (C) 2001 Lippincott Williams & Wi lkins.