Diabetic nephropathy: from micro- to macroalbuminuria

Abstract

This brief review will focus on the major factors leading to incipient diabetic nephropathy (i.e. microalbuminuria) progressing to overt nephropathy (i.e. macroalbuminuria) and particularly on the role of glycaemic control and hypertension. Both experimental and cohort studies support the role of hyperglycaemia in the development of diabetic nephropathy. Some recent long-term interventional studies in microalbuminuric patients show conflicting results regarding the role played by good metabolic control in reducing the incidence of overt nephropathy. However, strict metabolic control, which is fundamental in normoalbuminuric patients, is of little use even in microalbuminuric patients. In general, levels of glycosylated haemoglobin less than two standard deviations above the upper normal range, commonly <7.5-8%, seem to protect patients from developing nephropathy. The results of many cross-sectional studies have shown that the progression of renal damage regularly is accompanied by arterial hypertension both in insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM). Many long-term interventional studies have been performed in order to understand the effect of antihypertensive treatment on the incidence of proteinuria in both normotensive and hypertensive patients with IDDM or NIDDM. These data show a marked effect of antihypertensive therapy in preventing the onset of overt nephropathy, and suggest the superiority of angiotensin-converting enzyme (ACE) inhibitors. We believe that optimal blood pressure values are approximately 120/70-75 mmHg in younger patients and 125-130/80-85 mmHg in older patients. In conclusion, antihypertensive treatment, ACE inhibitors per se and possibly strict metabolic control reduce the development of nephropathy, thus playing a striking role in the secondary prevention of renal failure.

Evaluation of Self Management Behavior of Chronic Kidney Disease Patients

“…This can be probably explained by the increased diabetes prevalence in older population [15,16] and also long standing uncontrolled hyperglycaemia that has been known to be responsible for development of diabetic nephropathy [17,18]. In addition to older age, it is not uncommon for patients with diabetes to have multiple co-morbidities.…”

Insights into the Relationship Between Hypertension and Albuminuria

“…Microalbuminuria occurs in 10-42% of patients with Type 1 and Type 2 diabetes and is associated with disease duration [78][79]. According to prospective cohort studies, microabuminuria independently predicts cardiovascular endpoints in Type 1 diabetes.…”

Effect of glycemic control on albumin excretion in urine in diabetics

“…2 Data obtained from both IDDM and NIDDM demonstrate that 6-8% of microalbuminuria patients develop Overt nephropathy whereas less than 2% patients with normoalbuminuria develop Overt nephropathy. 7 However most adverse effects are mediated through diverse metabolic pathways, there are four potential pathways linking hyperglycemia to changes within kidney, which can be linked to functional and structural changes characterising diabetic nephropathy. These are polyol pathway, nonenzymatic glycation, glucose auto-oxidation and de novo synthesis of diglycerol leading to protein kinase C and phospholipase A 2 activation.…”