Diabetic Nephropathy: Current Concept of Therapeutic Strategy Toward Self-Sufficiency

Diabetic nephropathy (DN) has been regarded as a non-restorative chronic kidney disease (CKD) under current concept of practice.The current definition of CKD and the conventional diagnostic markers such as serum creatinine or microalbuminuria unfortunately limit them to CKD stage 3. Treatment initiated at this late stage fails to restore renal function, but simply slows the renal disease progression toward end-stage renal disease dependant to renal replacement therapy.Recent study on vascular homeostasis in late stage DN reveals (1) defective angiogenic factors associated with an impaired nitric oxide production which explains the therapeutic resistance to vasodilator treatment.(2) abnormally elevated anti-angiogenic factors associated with a progressive reduction in peritubular capillary flow and a progressive decline in renal function.In contrast to the above observation, DN would become restorative if it would be recognized and treated at an early stage during normoalbuminuria (CKD stages 1,2) under which the vascular homeostasis is adequately functional.ACEI and ARB combination can enhance peritubular capillary flow, correct the chronic renal ischemia and therefore restore renal function.This innovative therapeutic strategy can effectively prevent the end-stage renal disease in DN.