An evidence-based review of ACE inhibitors in incipient diabetic nephropathy.

Diabetic nephropathy develops in approximately 35% of diabetics and is the leading cause of end-stage renal disease in North America. End-stage renal disease is associated with increased morbidity and mortality, and a large economic burden. Treatments that can prevent or postpone diabetic nephropathy are important therapeutic advances. Interventional studies in type I diabetes and type II diabetes have demonstrated a beneficial effect of improved glycemic control and good blood pressure control in delaying the progression of diabetic nephropathy. Angiotensin-converting enzyme (ACE) inhibitors have been found to be effective in delaying the progression of diabetic nephropathy in hypertensive as well as normotensive diabetics with early and advanced nephropathy. Microalbuminuria or incipient diabetic nephropathy is the earliest clinical expression of diabetic nephropathy and identifies patients at risk of further progression. Advanced or overt nephropathy is associated with a greater risk for coronary artery disease and mortality. It is possible that interventions aimed earlier in the cascade at preventing the development of overt nephropathy may result in greater clinical benefit. There is compelling evidence of the benefit of ACE inhibitors in preventing the progression of incipient diabetic nephropathy to overt diabetic nephropathy in normotensive diabetics.