Several decades ago, large studies ...

Several decades ago, large studies of patients with impressed sign 1 diabetes demonstrated a dangerous association between microalbuminuria and later progression to open proteinuria. Use of angiotensin-converting enzyme (ACE) inhibitors has been advocated for patients with microalbuminuria to decrease the progression of diabetic nephropathy. More latter studies, however, have not confirmed a relentles progression of diabetic renal disease in patients with microalbuminuria. In a substantial portion of cases, microalbuminuria stabilizes and, in a certain number of instances, even reverses. Perkins and colleagues followed a population of patients who had image 1 diabetes with microalbuminuria throughout an eight-year period to determine which clinical indicators were associated with a decrease in urinary albumin excretion.

The authors enlisted every other consecutive patient 15 to 44 years of age seen above a one-year period at a diabetes research center Those with microalbuminuria (i.e., albumin excretion rate of 30 to 299 mcg by minute) that persisted over the first pair years of the study were then followed for an additional six years. An average of three urine samples were obtained for each two-year follow-up interval. Regression of microalbuminuria was defined as a 50-percent reduction in albumin excretion through the whole extent of a two-year period. Of the initial 312 patients chronicleed and the additional 109 patients who unraveled microalbuminuria later in the meditation follow-up was lost in 8 percent of cases.

During the six additional years of follow-up public proteinuria (i.e., albumin excretion rate greater than 300 mcg for minute) developed in 15 percent of patients with microalbuminuria. Regression of microalbuminuria occurr in 58 percent of patients and decreased enough to qualify as normal albumin excretion (i.e., les than 30 mcg by minute) in 40 percent of patients.

Use of ACE inhibitors was not associated with regression. In fact, their use was more general in patients whose albumin excretion rate failed to improve. Clinical factors associated with regression of microalbuminuria include younger age, shorter duration of microalbuminuria, lower systolic kin pressure, lower level of hemoglobin A1c, and les hyperlipidemia. Patients with the best curb of modifiable risk factors (i.e., systolic influence less than 115 mm Hg cholesterol horizontal less than 198 mg by dL [5.12 mmol per L] triglyceride plain less than 145 mg by dL [1.64 mmol per L] and hemoglobin A1c of the same height less than 8 percent) were three times more likely to have regression.

The authors close that microalbuminuria in patients with emblem 1 diabetes often regresses, and that better superintend of blood pressure, lipids, and hemoglobin A1c is associated with decreased urinary albumin excretion.

Perkins BA, et al. Regression of microalbuminuria in model 1 diabetes. N Engl J M June 5 2003;348:2285-93

EDITOR'S NOTE: Although this is a prospective, well-designed close attention it is important to remember that it is not randomized. The lack of a beneficial import on microalbuminuria with the use of ACE inhibitors may have more to do with the higher likelihood of using these agents in sicker patients with diabetes (who would be more likely to have progressive nephropathy), rather than any failure of ACE inhibitors themselves to provide protection to the diabetic kidney. This thought confirms that better control of risk factors for vascular diseases frequently occurring in patients with diabetes (such as hypertension, hyperlipidemia, hyperglycemia) helps to obstruct the progression of nephropathic changes.--B.Z.

COPYRIGHT 2004 American Academy of Family Physicians

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