Abbreviations: ACE-i, angiotensin-converting-enzyme inhibitor; ARB, angiotensin II receptor blocker; BB, beta-blocker; CAD, coronary artery disease (mainly myocardial infarction); CCB, calcium channel blocker; CV, cardiovascular; nr, not reported; ns, not significant; TZ, thiazide (or thiazide-like) diuretic.

with T2DM are not as uniform as those noted among adults with T1DM (43). In a recent cross-sectional survey (44), using data from the Third National Health and Nutrition Examination Survey (NHANES III), 33% of diabetic adults with a glomerular filtration rate (GFR) < 60 ml/ min per 1.73 m2 showed no evidence of microalbuminuria, microalbuminuria, or retinopathy. Findings obtained from T2DM patients with non-albuminuric renal insufficiency (45) suggest that patients with T2DM can commonly progress to a significant degree of renal impairment while remaining normo-albuminuric.

The two main treatment strategies for primary prevention of diabetic nephropathy are improved glycemic control and BP lowering, particularly using drugs such as ACEi. Megatrials and meta-analyses have clearly demonstrated the beneficial effect of both treatment modalities. Antihypertensive treatment of patients with overt diabetic nephropathy induces a reduction in albuminuria, a reduction in the rate of glomerular filtration rate, delays development of ESRD and improves survival of the patients. These benefits have been demonstrated with a variety of BP lowering agents, including BB, CCB, diuretics and ACEi.

Lewis and co-workers (46) compared captopril with placebo over 3 years in 409 T1DM patients with mild renal insufficiency due to DN (proteinuria > 500 mg/24h, serum creatinine level < 2.5mg/dl). Captopril treatment nearly halved the rate of increased serum creatinine levels, requirement of dialysis or transplantation or death. The difference in the median DBP during the study was less than 4 mm Hg. Unfortunately, no long-term study has been published concerning the effects of ACEi on the progression of DN in T2DM patients.

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