Kidney protection: a key target in the management of patients with diabetes

The need to prevent the development of renal damage and its associated increase in cardiovascular risk in patients with type 2 diabetes is well established. Early intervention to maintain strict blood pressure control and to prevent the development of microalbuminuria is mandatory and will constitute the primary aim of intervention in patients with diabetes and also in prediabetes, characterized by the presence of cardiometabolic risk. If microalbuminuria is already present, similar blood pressure control and normalized urinary albumin excretion are required. If diabetic nephropathy is established, similar blood pressure and albumin targets must be achieved. In this regard, data from the ADVANCE study suggest that the combination of perindopril and indapamide can greatly help clinicians to achieve these targets. This combination on top of standard treatment significantly reduced the risk of renal events by 21% (P < 0.0001), the progression of albuminuria by 22% (P < 0.0001), and increased the regression of albuminuria by 16% (P = 0.002). Furthermore, the rate of renal events decreased log-linearly with decreasing follow-up blood pressure, down to systolic blood pressure below 110 mmHg. According to the ADVANCE results, treatment with the perindopril/indapamide fixed combination on top of contemporary cardiovascular care prevents one renal event in 20 patients with type 2 diabetes treated over 5 years. Evidence of renal protection is added to the reduction in total and cardiovascular mortality in the main ADVANCE trial.