Diabetic nephropathy: evidence for renoprotection and practice.

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