Blog entry by Meguid El Nahas
A paper by Rosolowsky et al from the Joslin Clinic in Boston reviews the incidence of ESRD in T1DM patients with macroalbuminuria over the last 15-20 years. Whilst ESRD risk increases with advancing stages of CKD, as expected.The incidence of ESRD seems to have changed little over the observation period from 1990 to 2006. A slight decrease in incident ESRD was noted in those between 20 and 29 years of age. But there was a steady increase in incident ESRD in older patients; 40-49 years. These observations are extremely interesting as they coincide with the age of RAAS (renin-angiotensin-aldosterone system) blockade era. It started with the paper by Lewis et al in 1993 and is ongoing to our days.
However, and in spite of the obsession with ACE inhibition and angiotensin-receptor blockade (ARBs) in patients with diabetes, proteinuria and nephropathy, there seems to be little noticeable impact of the progression of diabetic kidney disease as judged by the lack of impact on incident ESRD in a large cohort over 15 years of observation?! Could it be that these agents had little impact beyond the control of hypertension (as suggested a few years ago by Cassas et al.) and may have even been detrimental in older patients with diabetic nephropathy and macrovascular disease? Watch this space; the myth of the superiority of ACE inhibitors and ARBs may be unravelling...in the meanwhile more imaginative and novel interventions are urgently needed to stem the rising tide of ESRD due to diabetes.