Diabetic nephropathy is characterized by proteinuria and progressive kidney failure. Since the late 1990s, the occurrence of diabetic nephropathy has been steadily increasing; this condition is now the dominant cause of end-stage renal disease (ESRD) in many countries. The increasing prevalence of diabetic nephropathy is primarily attributable to the growing numbers of people who have type 2 diabetes mellitus (1).
Type 2 diabetic patients have a cardiovascular risk equivalent to nondiabetic individuals with a previous acute myocardial infarction.2 More importantly and often poorly appreciated, diabetic patients with early diabetic nephropathy (proteinuria or a minimally elevated serum creatinine >1.5 mg/dl) have an even greater cardiovascular risk.3 The degree of proteinuria correlates with this risk so that patients with macroalbuminuria have an even higher risk for coronary events than those with microalbuminuria. Abnormalities in vitamin D, parathyroid hormone, and calcium metabolism in patients with even moderate kidney failure lead to vascular and particularly coronary calcification,4 and this surely contributes to the high incidence of cardiovascular events. Once a patient reaches ESRD, the average survival on dialysis in the United States is 4–5 years, with death generally resulting from cardiovascular events or infection.
In the late 1970s, dialysis for patients with diabetes, who frequently have advanced cardiovascular complications, could provide only a limited benefit because of technical problems and insufficient options for medical treatment. As a result, patient survival at that time was poor. However, improvements in medical technologies and medicines, advances in the treatment of coronary artery disease and in critical care medicine, and introduction of earlier initiation of renal replacement therapy have combined to improve outcomes, with the result that dialysis for diabetic patients is now a widely accepted standard clinical practice.
The course of diabetic nephropathy is similar in type 1 and type 2 diabetes, although the diagnosis of type 2 diabetes is frequently delayed because of its insidious nature, giving the appearance of an earlier onset of nephropathy in type 2 diabetes. Microalbuminuria predicts the progression to diabetic nephropathy in 80% of untreated patients with type 1 diabetes and is rarely seen when patients have been diagnosed <5 years. Macroalbuminuria generally develops within 10 years, followed by a progressive rise in serum creatinine, eventually leading to ESRD requiring dialysis or transplantation. In contrast, microalbuminuria is commonly seen in patients with type 2 diabetes at the time of diabetes diagnosis or shortly thereafter and signifies vascular endothelial injury and increased cardiovascular risk.6 It is considered more a feature of the insulin resistance syndrome,7 and only 20–40% of these patients will progress to macroalbuminuria and kidney failure. The diagnosis of type 2 diabetes at an older age also leaves less time for ESRD to develop.
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