Limitations and Future Treatment Options in Type 2 Diabetes With Renal Impairment

In the past two decades, nephropathy in type 2 diabetes has emerged as a major public health issue. The purpose of this presentation is to review the epidemiology of diabetic nephropathy, the controversy surrounding HbA1c and blood pressure as targets for treatment, the efficacy of blocking the renin-angiotensin system (RAS) pathway, and finally the available add-on therapies in patients with “escape.” Diabetic nephropathy in type 1 and type 2 diabetes emerged as a major issue in the 1970s, but knowledge of albuminuria in patients without primary kidney disease goes back to the work of Senator (1), who found albumin excretion in the urine of roughly 10% of the general population, including individuals with diabetes. In 1891, Schmitz (2) found albuminuria in 10–26% of diabetic patients and discussed its etiology and prognostic implications. Renal failure in patients with diabetes became a major issue when continuously increasing numbers of diabetic patients were admitted for renal replacement therapy—a veritable “medical catastrophe of worldwide dimension” (3). According to the U.S. Renal Data System report, diabetes accounted for 54% of new patients in 2007. The incidence of end-stage renal disease (ESRD) in diabetic patients is currently 155 patients per million per year; it decreased by 3.3% between 2006 and 2007. In recent years, the prevalence was ∼600 patients per million per year, illustrating the dimension of the problem. In our own local experience in Heidelberg (4), 49%, or 98 patients per million per year, admitted for renal replacement therapy had diabetes; of these patients, 6% had type 1 diabetes, and 94% had type 2 diabetes. Recently, however, the rate of admission of type 2 diabetic patients for renal replacement therapy reached its plateau (5) in Denmark and in Europe in general. Observations in the Pima Indian population show that there is a significant decrease …