Diabetic Nephropathy

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Abstract
Diabetes has become the most common single cause of end-stage renal disease (ESRD) in the U.S. and Europe; this is due to the facts that 1 ) diabetes, particularly type 2, is increasing in prevalence; 2 ) diabetes patients now live longer; and 3 ) patients with diabetic ESRD are now being accepted for treatment in ESRD programs where formerly they had been excluded. In the U.S., diabetic nephropathy accounts for about 40% of new cases of ESRD, and in 1997, the cost for treatment of diabetic patients with ESRD was in excess of $15.6 billion. About 20–30% of patients with type 1 or type 2 diabetes develop evidence of nephropathy, but in type 2 diabetes, a considerably smaller fraction of these progress to ESRD. However, because of the much greater prevalence of type 2 diabetes, such patients constitute over half of those diabetic patients currently starting on dialysis. There is considerable racial/ethnic variability in this regard, with Native Americans, Hispanics (especially Mexican-Americans), and African-Americans having much higher risks of developing ESRD than non-Hispanic whites with type 2 diabetes. Recent studies have now demonstrated that the onset and course of diabetic nephropathy can be ameliorated to a very significant degree by several interventions, but these interventions have their greatest impact if instituted at a point very early in the course of the development of this complication. This position statement is based on recent review articles that discuss published research and issues that remain unresolved and provides recommendations regarding the detection, prevention, and treatment of early nephropathy. The earliest clinical evidence of nephropathy is the appearance of low but abnormal levels (≥ 30 mg/day or 20 μg/min) of albumin in the urine, referred to as microalbuminuria, and patients with microalbuminuria are referred to as having incipient nephropathy. Without specific interventions, ∼80% of subjects with …