Prevention of Progression in Diabetic Nephropathy

Mogensen1 made the unique observation that lowering blood pressure in patients with type 1 diabetes and diabetic nephropathy reduced the rate of loss in kidney function. In that study of five insulin-dependent proteinuric men with long-standing diabetes, blood pressure was lowered with combinations of furosemide, prazosin, hydralazine, and -blockers. This observation presaged what has become a crucial intervention in diabetic nephropathy: that lowering systemic blood pressure has been repeatedly shown to alter the course of diabetic kidney disease. Great progress has been made in understanding some of the other mechanisms of this disorder and in delaying its clinical expression and preventing its progression. The importance of diabetic nephropathy as a cause for patient morbidity and mortality is well known. Diabetic nephropathy occurs in ~ 30% of people with type 1 diabetes and 25–40% of people with type 2 diabetes, often irrespective of glycemic control. Diabetic nephropathy is the single most common cause of endstage renal disease (ESRD) in the United States, accounting for > 50% of new cases of renal failure. Patients who have diabetes and reach ESRD have a poor prognosis because of high cardiovascular events. Thus, early identification of patients who have diabetes and are at high risk for nephropathy is mandatory in order to prevent the development or progression of diabetic nephropathy. This article will review what is known about the major mechanisms and risk factors promoting renal injury in diabetes and will summarize the evidence-based recommendations for preventing progression.