Changing Treatment Targets And Microalbuminuria

Since the initial concept of microalbuminuria in the early 1980's, there have been significant changes in approaches to the control of hyperglycaemia and hypertension. The DCCT (1997) [31] and UKPDS (1998) [32] studies were responsible for lowering HbA1c targets to <7.0% and the captopril study (1993) [33] and IRMA-2 [24], IDNT [34] and RENAAL (2001) [35] studies were responsible for the widespread use of antihypertensive therapy based on inhibition of the renin angiotensin system with blood pressure targets to below 130/85 in patients with early and late diabetic nephropathy [36]. Although these targets are achieved in less than half of eligible patients in community based surveys, the earlier use of insulin in type 2 diabetes and the use of multiple antihypertensive agents are now part of 'standard' therapy, whereas they would have been considered inappropriate 20 years ago, when HbA1c had just been introduced and blood pressure levels of less than 160/95 were considered normotensive. Since glycaemic control is critical in the initiation of nephropathy, and both glycaemic and blood pressure control determine the rate of progression of nephropathy, it follows that consideration of a calendar effect is important in evaluating AER and GFR studies during the last 20 years.

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