Continuously evolving management concepts for diabetic CKD and ESRD

During the past 50 years, a global pandemic of kidney failure attributed to diabetes mellitus provoked continuously changing treatment strategies based in the belief that micro- and macrovascular complications of diabetes may be preventable. Both patient and physician have revised, and sometimes reversed drug regimens based on inferences extracted from prospective, controlled, properly populated trials. Illustrating this dilemma is a newly relaxed target for glycosylated hemoglobin (HbA1c) of 7%, introduced because of the greater rate of cardiovascular complications noted when striving to reduce attained HbA1c to < or = 6.5%. Our concept of the natural history of kidney disease in diabetes has repeatedly been modified by a rising mean age of those developing uremia (now 64.5 years). Underscoring the reality that the majority of diabetic kidney failure patients fall within the geriatric age group. An encouraging finding first reported in 2005 and continuing through 2009 is a declining incidence rate of irreversible advanced kidney failure in individuals known to have diabetes. That this "good news" results from appropriate renoprotective treatment is as yet unsubstantiated wishful thinking.