Therapeutic management of diabetic kidney disease

Abstract

During the past 10 years, a global pandemic of end-stage renal disease (ESRD) attributed to diabetes mellitus has changed the therapeutic strategies based on landmark trials that have shown that diabetic micro- and macrovascular complications might be preventable. However, the remaining risk of the progression of diabetic kidney disease to ESRD is still high, despite newly introduced anti-diabetic, antihypertensive and dyslipidemic drugs in the 21st century. Here, we show the importance of targeting remission and regression of microalbuminuria in type 2 diabetic patients. To achieve the remission and regression of microalbuminuria, physicians have revised the management strategy of diabetic patients and have to act immediately. Early detection of microalbuminuria with continuous screening, the use of renin-angiotensin system blockades, and targets for HbA1c of <7.35% and systolic blood pressure of <130 mmHg are closely associated with the remission and regression of microalbuminuria, resulting in protection against the progression of diabetic kidney disease, as well as cardiovascular events. Our concept of the natural history of diabetic kidney disease has to be modified by our results and others. Reducing microalbuminuria is therefore considered to be an important therapeutic target and could be a pivotal biomarker of therapeutic success in diabetic patients. (J Diabetes Invest, doi:10.1111/j.2040-1124.2011.00112.x, 2011).

Keywords: Microalbuminuria; Overt proteinuria; Remission.

Figure 1

Landmark studies showing the effectiveness of renin–angiotensin system inhibitors on diabetic kidney disease, and cardiovascular mortality and morbidity.

Figure 2

A prospective observational follow‐up study including a total of 216 Japanese type 2 diabetic patients with microalbuminuria was carried out to follow the change of stage of microalbuminuria for 6 years. The remission was defined as a shift of the albumin excretion rate (AER) from microalbuminuria to normoalbuminuria, and the regression was defined as 50% reduction in the AER from baseline.

Figure 3

A prospective observational follow‐up study including a total of 216 Japanese type 2 diabetic patients with microalbuminuria was carried out to explore the clinical impact of remission and progression of microalbuminuria. The primary evaluation consisted of combined incidence defined as cardiovascular death and first hospitalization for renal and cardiovascular events. The pooled logistic analysis adjusted by sex, age, the initial albumin excretion rate levels, a history of cardiovascular disease, current smoking, HbA_1c, total cholesterol, triglyceride, high‐density lipoprotein cholesterol, systolic blood pressure, diastolic blood pressure, the use of renin–angiotensin system inhibitors, the use of lipid lowering drugs and body mass index showed that the risk for outcomes in patients, who achieved remission, was 0.25 (95% CI 0.07–0.87) as compared with those whose microalbuminuric stage did not change during the follow up, whereas that in patients, who progressed to overt proteinuria, was 2.55 (95% CI 1.04–6.30).