Diabetic Nephropathy

Diabetic nephropathy accounts for 30 to 50% of all causes of ESRD. An interplay between systemic and intrarenal hemodynamics, glycemic control, genetic predisposition, and ethnic background culminate in progressive decline in GFR in a large fraction of IDDM and NIDDM patients. Efforts to maintain euglycemia, to stop smoking, and to control blood pressure (especially with ACE inhibitors) are most likely to be rewarded by prevention or slowing of the progression of diabetic nephropathy and should reduce extrarenal vascular injury as well. Microalbuminuric, even normotensive, patients may enjoy especially great advantage by ACE-inhibition therapy. ESRD therapy in these patients often begins earlier and remains complicated by ongoing extrarenal complications of diabetes. Renal transplantation offers good results, but preoperative screening for coronary disease is critical to reducing death with a functioning graft. Combined kidney-pancreas transplant may represent some increased risk over kidney transplant alone, but can be highly beneficial in well-selected patients.