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Diabetic nephropathy: evidence for renoprotection and practice
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  1. Carl-Erik Mogensen
  1. Department of Endocrinology and Diabetes, Århus Kommune Hospital, Århus University of Hospital, Nørrebrogade, DK-8000 Århus C, Denmark
  1. Professor Mogensen email:cem{at}afdm.au.dk

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Patients with diabetic renal disease have a very bad prognosis. Hyperfiltration, related to poor metabolic control, occurs early on in the disease process.1 There is also an increase in albumin excretion which can be readily reversed by effective glycaemic control at clinical diagnosis (fig 1).

Figure 1

The natural course of diabetic nephropathy in type 1 diabetes.

A phase is then entered during which most patients are normoalbuminuric. However, after approximately 10 years, some patients will develop microalbuminuria. The risk of progression from normal to microalbuminuria is closely related to poor metabolic control and also, to some extent, blood pressure elevation. In patients with type 1 or type 2 diabetes and microalbuminuria there is advanced structural damage in the kidney.

Later, patients develop overt nephropathy and in type 1 and type 2 diabetes there is a relentless decline in glomerular filtration rate (GFR).

Role of angiotensin converting enzyme inhibitors

In recent years there has been an increased focus on treating patients early to prevent future renal damage. Even before microalbuminuria has developed there is evidence of the benefits of angiotensin converting enzyme (ACE) inhibitors.

NORMAL ALBUMINURIA

In studies looking at renal haemodynamics, ACE inhibitors were used to treat patients with type 1 diabetes who had normal albumin excretion.2 A reduction in filtration fraction was observed with ACE inhibitor treatment suggesting that the pressure at the glomerular membrane was reduced. The albumin excretion rate was also reduced in these completely normo-albuminuric …

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