Abstract
Diabetic nephropathy is the most common cause of terminal renal failure in developed countries. Albuminuria precedes the development of manifest diabetic nephropathy in most diabetic patients and is also the most significant predictor of cardiovascular mortality/ morbidity in these patients.
Progression of albuminuria can be favourably affected by both good metabolic control of diabetes and good blood pressure control. Angiotensin-converting enzyme inhibitors and angiotensin antagonists reduce albuminuria and slow down (but do not stop) the progression of chronic renal insufficiency.
Despite this treatment, most patients will develop terminal renal failure unless they die of cardiovascular disease before that. Combining both drugs is not likely to have a greater antiproteinuric effect than monotherapy with an angiotensin-converting enzyme inhibitor.
A further reduction in albuminuria (or proteinuria) in diabetic patients can be achieved by using the direct renin inhibitor aliskiren or endothelin antagonists. The high cardiovascular mortality/morbidity of patients with diabetic nephropathy can be lowered by reducing albuminuria and decreasing systolic blood pressure.
Angiotensin antagonists reduce the risk of heart failure in patients with diabetic nephropathy; the evidence of a beneficial effect of renin-angiotensin system inhibition on the risk of myocardial infarction is less unequivocal.