Diabetic nephropathy

Diabetic nephropathy is the most common cause of end-stage renal disease (ESRD) and accounts for 35% of the ESRD population in the United States. It results in considerable morbidity, mortality, and expense. The average cost of managing one diabetic patient with ESRD is approximately $50,000 a year. Over the last decade, several advances in the management of diabetic nephropathy have allowed physicians to intervene and retard the progression of renal failure in patients with diabetic nephropathy. Stalling the progression of renal failure allows patients to maintain a superior quality of life and saves society millions of dollars that can be allocated to other aspects of health care. The prevalence of diabetes mellitus continues to increase. With the continued advances in medical technology and care, persons with this disease will live longer, and the incidence of diabetic nephropathy will increase. Primary care physicians will have the most frequent contact with these patients and therefore will have the greatest potential to favorably affect their clinical course. This review focuses on the therapeutic interventions available to delay the progression of diabetic nephropathy. Clinicians should strive to secure euglycemia and obtain optimal blood pressure control in their patients. The unique renal-protective effects of angiotensin-converting enzyme inhibitors will be reviewed, as will the salutary effects of a low-protein diet, normalizing serum cholesterol, and the cessation of smoking. The optimal timing of dialysis access placement and the initiation of dialysis and transplantation will also be discussed.