Early nephropathy in type 1 diabetes: a new perspective on who will and who will not progress

Impaired renal function and end-stage renal disease (ESRD) affect up to a third of patients with type 1 diabetes. Thus, strategies for early detection and for preventative interventions are of critical importance. A model of diabetic nephropathy was developed in the 1980s that placed paramount importance on the finding of microalbuminuria as an early marker of a committed process of progressive kidney disease in diabetes. However, recent studies have provided evidence that microalbuminuria is a marker of dynamic, rather than fixed, kidney injury. Preliminary studies into early renal function decline, a process measured in early nephropathy using a simple assay for cystatin C to calculate the slope of glomerular filtration rate change over time, suggest that it is a more proximal marker than microalbuminuria of a person's trajectory toward impaired renal function and ESRD. Therefore, early renal function decline, rather than microalbuminuria, may be considered as the early marker of the committed process underlying progressive diabetic nephropathy.