Diabetic renal disease in patients with type 2 diabetes mellitus: new strategies for prevention and treatment.

Over the last 35 years an increasing number of patients with type 2 diabetes mellitus have developed advanced renal disease and the need for dialysis. At present in the US, about 50% of the patients in dialysis units have type 2 diabetes mellitus. The explanation for the increase in the number of patients with type 2 diabetes mellitus in end-stage renal disease programs is not completely clear, but the overall number of patients with this type of diabetes is rapidly increasing - and is expected to continue to increase over the next years. The diagnosis of renal disease in type 2 diabetes mellitus is usually straightforward, and is mainly dependent upon measurements of urinary albumin or urinary protein excretion as well as serum creatinine measurements. Renal biopsies or exact glomerular filtration rate measurements are rarely necessary. Microalbuminuria is the first sign of renal disease in diabetes mellitus. It predicts overt nephropathy and cardiovascular disease. Several studies document that albuminuria and microalbuminuria can be reduced by treatment with antihypertensives, especially agents that block the renin angiotensin system. New studies show that end-stage renal disease can be postponed by the use of angiotensin II receptor antagonists. ACE inhibitors are also useful, and dual blockade of the renin angiotensin system has been utilized as well. However, generally speaking, patients with proteinuria have a poor prognosis. Screening for microalbuminuria is therefore proposed, and glycemic control and blood pressure should be optimized.