[Primary prevention of diabetic nephropathy]

Microalbuminuria is not only a risk factor for diabetic nephropathy but also for cardiovascular morbidity and mortality. Microalbuminuria is a marker of endothelial dysfunction, which is a promoter of atherosclerosis. In type 1 diabetes, intensive glucose control decreases the microalbuminuria risk by 20-30%. In patients with this type of diabetes, microalbuminuria prevention is associated with a significant reduction of cardiovascular events. In type 2 diabetes, good metabolic control is similarly effective in microalbuminuria prevention, as shown by the ACCORD, ADVANCE and VADT studies. The role of renin-angiotensin system inhibition in the prevention of microalbuminuria is still unclear. In type 1 diabetes, there are no studies available showing that drugs inhibiting the renin-angiotensin system are able to prevent albuminuria. In patients with type 2 diabetes there are contrasting data: ACE-inhibitors prevent the appearance of microalbuminuria, while angiotensin receptor blockers do not prevent albuminuria or are associated with adverse effects. Therefore in type 2 diabetes patients with normoalbuminuria there is evidence that ACE inhibitors are effective in preventing microalbuminuria only in those patients with hypertension. In these patients good metabolic control and ACE inhibitor therapy are clearly able to prevent microalbuminuria.