Atrial natriuretic peptide-induced microalbuminuria is associated with endothelial dysfunction in noncomplicated type 1 diabetes patients

Progress and prospects of Sacubitril/Valsartan: Based on heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) is present in nearly half of patients with heart failure. The prevalence of heart failure with normal or near-normal ejection fractions increases more rapidly than in patients with reduced ejection fractions. Angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), aldosterone antagonist, β-blocker, and calcium channel blocker have not shown significant efficacy in HFpEF clinical trials. Sacubitril/Valsartan, combined angiotensin receptor blocker (Valsartan) with neprilysin inhibitor (Sacubitril), was the first-of-its-kind angiotensin receptor-neprilysin inhibitor (ARNI) to be developed. It has shown significant efficacy on HFpEF in recent studies. It is considered that most of the current Sacubitril/Valsartan studies are still concentrated in the field of heart failure, especially heart failure with reduced ejection fraction (HFrEF). This review discusses the latest advances in cardiovascular, renal, and metabolic aspects of Sacubitril/Valsartan, mainly in HFpEF, providing more evidence for further future research on Sacubitril/Valsartan and raising issues that should be paid attention. At the same time, this review will introduce the academic consensus on Sacubitril/Valsartan in treating HFpEF in China.

Effect of Sacubitril/Valsartan on renal function in patients with chronic kidney disease and heart failure with preserved ejection fraction: A real-world 12-week study

Patients with chronic kidney disease (CKD) are often complicated with heart failure with preserved ejection fraction (HFpEF). However, several drugs, including angiotensin-converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB), have not shown apparent benefits in terms of morbidity and mortality of HFpEF. PARAMOUNT and other studies have shown the potential benefits of Sacubitril/Valsartan on patients with HFpEF, but its effects on renal function and the effect of low-dose Sacubitril/Valsartan in actual clinical conditions have not been thoroughly evaluated. In our longitudinal and observational research, 353 patients were followed up for 12 weeks. We evaluated renal function [urinary protein, serum creatinine and estimated glomerular filtration rate (eGFR)] and cardiac function [NT-proBNP (brain natriuretic peptide), New York Heart Association (NYHA) classification, left ventricular ejection fraction (LVEF), left atrial width and left ventricular end-diastolic width] at baseline and during follow-up. Worsening renal function (WRF) was defined as an increased serum creatinine≥26.5umol/L or decreased eGFR≥20%. The decline of eGFR in the Sacubitril/Valsartan group was slower than that in the control group (p = 0.021). The outcome of proteinuria in the ACEI/ARB group was significantly better than that in the Sacubitril/Valsartan group (p = 0.001). In terms of echocardiogram, the average left atrial width in Sacubitril/Valsartan group decreased by 1.38 ± 3.02 mm, which was significantly lower than that in the ACEI/ARB group (p = 0.02). The increase of urine protein class in the ACEI/ARB group increased the risk of WRF with statistical significance (OR = 2.36, 95%CI 1.01-5.49, p = 0.047), but no statistical significance was found in all the patients or Sacubitril/Valsartan group. In conclusion, Sacubitril/Valsartan could more effectively slow down renal function decline and reverse myocardial remodeling in patients with CKD and HFpEF than ACEI/ARB, even at low doses, though its protective effect on urinary protein is not as good as that of ACEI/ARB.

Effect of Angiotensin-Neprilysin Versus Renin-Angiotensin System Inhibition on Renal Outcomes: A Systematic Review and Meta-Analysis

Aims: We aim to perform a systematic review and meta-analysis examining randomized controlled trials assessing the efficacy and safety of sacubitril/valsartan in patients on renal outcomes, in comparison with the renin–angiotensin–aldosterone system inhibitor (RAASi).

Methods: Eligible studies were retrieved on MEDLINE, EMBASE, and Cochrane until September 2021. The primary outcome was the incidence of renal impairment, which was defined as the composite of increases in serum creatinine by >0.3 mg/dl and/or a reduction in eGFR ≥25%, development of ESRD, or renal death. We pooled relative risks (RRs) with 95% confidence intervals (CIs) or the mean difference with 95% CIs for the variables.

Results: Our search yielded 10 randomized controlled trials with a total of 18,362 patients. Compared with RAASi treatment, patients treated with sacubitril/valsartan had lower incidence of composite renal impairment (10 studies, 18,362 patients, RR 0.84; 95% CI 0.72–0.96, p = 0.01; I² = 22%), ESRD development (3 studies, 13,609 patients, RR 0.53; 95% CI 0.30–0.96, p = 0.03; I² = 0%), drug discontinuation due to renal events (4 studies, 9,995 patients, RR 0.58; 95% CI 0.40–0.83, p = 0.003; I² = 47%), severe hyperkalemia (6 studies, 16,653 patients, RR 0.80; 95% CI 0.68–0.93, p = 0.01; I² = 25%) and a slower eGFR decline (4 studies, 13,608 patients, WMD 0.56; 95% CI 0.36–0.76, p < 0.00001; I² = 65%). Subgroup analysis demonstrated that sacubitril/valsartan was associated with a lower incidence of renal impairment in patients with heart failure and preserved ejection fraction (HFpEF), but not in those with heart failure and reduced ejection fraction (HFrEF). The superior renal function preservation of sacubitril/valsartan treatment was not associated with different baseline eGFR levels and follow-up duration. There was a smaller increase in the change in the urine albumin-to-creatinine ratio (UACR) (3 studies, 9,114 patients, SMD 0.06; 95% CI 0.02–0.10, p = 0.003; I² = 14%) with sacubitril/valsartan treatment. However, patients with heart failure appeared to have increased microalbuminuria, not patients without HF (p = 0.80 for interaction).

Conclusion: Sacubitril/valsartan was associated with a lower incidence of composite renal impairment especially in patients with HFpEF, but higher microalbuminuria in patients with heart failure (both HFrEF and HFpEF) compared with RAASi. The lower incidence of severe hyperkalemia and drug discontinuation due to renal events in patients with sacubitril/valsartan treatment demonstrated its superior safety compared with RAASi.

Effects of angiotensin receptor neprilysin inhibitor on renal function in patients with heart failure: a systematic review and meta-analysis

The angiotensin receptor neprilysin inhibitor (ARNI) has been recommended as a first-line treatment in patients with heart failure (HF). However, the effects of ARNI on renal function remain controversial.The PubMed, Embase, the Cochrane Library of Trials and Web of Science were searched in the period from inception to 31 January 2021. Randomised controlled trial, cohort studies and observational studies reporting at least one of renal function indicators were included.In patients with HF with reduced ejection fraction (HFrEF), ARNI did not lead to a significant decrease in estimated glomerular filtration rate (eGFR, p=0.87), and the risk of worsening renal function (WRF) dropped by 11% compared with control group. Though the level of serum creatinine (SCr) and serum potassium had a slight increase (p=0.01; p=0.02), in contrast to the baseline level, but without clinical significance. In patients with HF with preserved ejection fraction (HFpEF), the level of SCr and serum potassium did not have a significant change, and patients with HFpEF assigned to ARNI had a much lower rate of WRF (p=0.0007). In contrast to control group, both patients with HFrEF and HFpEF had a less decrease in eGFR and a lower rate of hyperkalaemia in ARNI group.ARNI did not lead to a significant decrease in eGFR in HFrEF. Compared with control group, ARNI could delay the progression of decrease in eGFR and result in less events of hyperkalaemia in patients with HF. Besides, patients with HFpEF had a lower rate in the events of WRF.

Role of the sodium-hydrogen exchanger in mediating the renal effects of drugs commonly used in the treatment of type 2 diabetes

Diabetes is characterized by increased activity of the sodium-hydrogen exchanger (NHE) in the glomerulus and renal tubules, which contributes importantly to the development of nephropathy. Despite the established role played by the exchanger in experimental studies, it has not been specifically targeted by those seeking to develop novel pharmacological treatments for diabetes. This review demonstrates that many existing drugs that are commonly prescribed to patients with diabetes act on the NHE1 and NHE3 isoforms in the kidney. This action may explain their effects on sodium excretion, albuminuria and the progressive decline of glomerular function in clinical trials; these responses cannot be readily explained by the influence of these drugs on blood glucose. Agents that may affect the kidney in diabetes by virtue of an action on NHE include: (1) insulin and insulin sensitizers; (2) incretin-based agents; (3) sodium-glucose cotransporter 2 inhibitors; (4) antagonists of the renin-angiotensin system (angiotensin converting-enzyme inhibitors, angiotensin receptor blockers and angiotensin receptor neprilysin inhibitors); and (5) inhibitors of aldosterone action and cholesterol synthesis (spironolactone, amiloride and statins). The renal effects of each of these drug classes in patients with type 2 diabetes may be related to a single shared biological mechanism.

Elevated High Sensitivity C-Reactive Protein Increases the Risk of Microalbuminuria in Subjects With Cardiovascular Disease Risk Factors

Microalbuminuria is an early biomarker of kidney injury, the aim of this study was to investigate the impact of high sensitivity C-reactive protein (hs-CRP) on microalbuminuria in adults with cardiovascular disease (CVD) risk factors. A total of 5667 subjects who voluntarily attended annual health screenings in the Third Xiangya Hospital of Central South University were included in the study. Logistic regression was used to determine the validity of hs-CRP to predict the presence of microalbuminuria. In the unadjusted regression analysis, male gender (OR 2.23), age (OR 1.71), smoking status (OR 1.48), obesity (OR 2.41), hypertension(OR 4.03), diabetes (OR 4.61), hyperuricemia (OR 1.83), and high hs-CRP(OR 1.61) were associated with microalbuminuria. Multivariate logistic regression analysis showed that the adjusted odds ratios (OR) of diabetes, hypertension, male, abdominal obesity, and high hs-CRP for microalbuminuria were 2.71, 2.57, 1.51, 1.28 and 1.41 in all subjects, respectively (P < 0.01). ROC analysis indicated that the cut-off for hs-CRP with better properties for screening of microalbuminuria was identified as ≥0.85 mg/L. The ORs of microalbuminuria were 1.97, 1.49, 1.32 and 1.71 times in male, abdominal obesity, diabetes and hypertension subjects with hs-CRP ≥ 0.85 mg/L, respectively, compared with those without elevated hs-CRP (P < 0.01). Elevated hs-CRP level was associated with microalbuminuria independent of cardiovascular risk factors. In addition, elevated hs-CRP increased the risk of developing microalbuminuria in subjects with CVD risk factors, indicating that chronic inflammation could amplify the deterioration of kidney by effect of CVD risk factors.

Increased plasma concentrations of midregional proatrial natriuretic Peptide is associated with risk of cardiorenal dysfunction in type 1 diabetes

BACKGROUND

To examine possible associations between midregional proatrial natriuretic peptide (MR-proANP) and diabetic complications at baseline and risk of mortality and end-stage renal disease (ESRD) during follow-up in type 1 diabetes.

METHODS

Observational study including 667 patients, with plasma MR-proANP measured at baseline. Complications were defined as micro- (n = 168) or macroalbuminuria (n = 190) (urinary albumin excretion rate (UAER) 30-299 or ≥ 300 mg/24h), previous cardiovascular disease (CVD) (n = 143), cardiac autonomic dysfunction (heart rate variability < 11 beats/min) (n = 369), and retinopathy (n = 523). Adjustments included gender, age, systolic blood pressure, estimated glomerular filtration rate (eGFR), UAER, HbA1c, total cholesterol, 24-hour urinary sodium excretion (24h-U(Na)), body mass index, daily insulin dose, antihypertensive treatment, and smoking in linear regression analyses and analysis of covariance models. Development of ESRD (dialysis, renal transplantation, or GFR/eGFR < 15 ml/min/1.73 m(2)) and mortality was recorded through national registers.

RESULTS

The cohort included 293 (44%) females, aged 55 ± 13 years. Plasma MR-proANP (median (interquartile)) was 74.7 (49.2-116.8) pmol/L. Adjusted, MR-proANP correlated positively with age and UAER and negatively with eGFR, 24h-U(Na), total cholesterol, and HbA1c (P < 0.05). Moreover, MR-proANP levels increased with albuminuria degree and were higher in patients with previous CVD (P ≤ 0.001), but similar in patients with or without autonomic dysfunction or retinopathy (P ≥ 0.076). During follow-up (3.5 (3.1-4.0) years), higher MR-proANP concentrations predicted ESRD and mortality combined (n = 35) adjusted for gender, age, systolic blood pressure, eGFR, and previous CVD (hazard ratio per 1SD increase in logANP: 2.8 (1.6-4.7; P < 0.001)).

CONCLUSIONS

Increased plasma MR-proANP was associated with impaired renal function, increased albuminuria, and previous CVD. Moreover, MR-proANP concentrations were associated with increased risk of development of ESRD and mortality combined during follow-up.

Renal effects of the angiotensin receptor neprilysin inhibitor LCZ696 in patients with heart failure and preserved ejection fraction

BACKGROUND

Increases in serum creatinine with renin-angiotensin-aldosterone system (RAAS) inhibitors can lead to unnecessary discontinuation of these agents. The dual-acting angiotensin receptor neprilysin inhibitor LCZ696 improves clinical outcome patients with heart failure with reduced ejection fraction, and pilot data suggest potential benefit in heart failure with preserved ejection fraction (HFpEF). The effects of LCZ696 on renal function have not been assessed.

METHODS AND RESULTS

A total of 301 HFpEF patients were randomly assigned to LCZ696 or valsartan in the PARAMOUNT trial. We studied renal function [creatinine, estimated glomerular filtration rate (eGFR), cystatin C, and urinary albumin to creatinine ratio (UACR)] at baseline, 12 weeks, and after 36 weeks of treatment. Worsening renal function (WRF) was determined as an serum creatinine increase of >0.3 mg/dL and/or >25% between two time-points. Mean eGFR at baseline was 65.4 ± 20.4 mL/min per 1.73 m(2) . The eGFR declined less in the LCZ696 group than in the valsartan group (-1.5 vs. -5.2 mL/min per 1.73 m(2) ; P = 0.002). The incidence of WRF was lower in the LCZ696 group (12%) than in the valsartan group (18%) at any time-point, but this difference was not statistically significant (P = 0.18). Over 36 weeks, the geometric mean of UACR increased in the LCZ696 group (2.4-2.9 mg/mmol), whereas it remained stable in the valsartan group (2.1-2.0 mg/mmol; P for difference between groups = 0.016).

CONCLUSION

In patients with HFpEF, therapy with LCZ696 for 36 weeks was associated with preservation of eGFR compared with valsartan therapy, but an increase in UACR.

Endothelial markers may link kidney function to cardiovascular events in type 2 diabetes

OBJECTIVE

The increased cardiovascular risk in diabetes has been linked to endothelial and renal dysfunction. The aim of this study was to investigate the role of stable fragments of the precursors of adrenomedullin, endothelin-1, vasopressin, and atrial natriuretic peptide in progression of cardiovascular disease in patients with diabetes.

RESEARCH DESIGN AND METHODS

This was a prospective, observational study design with a composite end point (death or unexpected admission to hospital due to a cardiovascular event) on 781 patients with type 2 diabetes (54 events, median duration of observation 15 months). The four stable precursor peptides midregional adrenomedullin (MR-proADM), midregional proatrial natriuretic peptide (MR-proANP), COOH-terminal proendothelin-1 (CT-proET-1), and COOH-terminal provasopressin or copeptin (CT-proAVP) were determined at baseline, and their association to renal function and cardiovascular events was studied using stepwise linear and Cox logistic regression analysis and receiver operating characteristic analysis, respectively.

RESULTS

MR-proADM, CT-proET-1, CT-proAVP, and MR-proANP were all elevated in patients with future cardiovascular events and independently correlated to serum creatinine. MR-proADM and MR-proANP were significant predictors of a future cardiovascular event, with MR-proANP being the stronger (area under the curve 0.802 +/- 0.034, sensitivity 0.833, specificity 0.576, positive predictive value 0.132, and negative predictive value 0.978 with a cutoff value of 75 pmol/l).

CONCLUSIONS

The four serum markers of vasoactive and natriuretic peptides are related to both kidney function and cardiovascular events, thus linking two major complications of diabetes, diabetic nephropathy and cardiovascular disease.

Relation of plasma midregional proatrial natriuretic peptide to target organ damage in adults with systemic hypertension

We tested the hypothesis that, in adults with essential hypertension, plasma levels of midregional proatrial natriuretic peptide (MR-proANP) are associated with target organ damage. MR-proANP is a newly described stable fragment of N-terminal proatrial natriuretic peptide. Participants included 1,919 adults with hypertension identified from the community (1,037 African-Americans, 65 +/- 9 years of age, 72% women; 882 non-Hispanic whites, 61 +/- 9 years of age, 55% women). We measured MR-proANP by an immunoluminometric assay. Measurements of target organ damage included the ankle-brachial index (ABI), urinary albumin-creatinine ratio (UACR), and left ventricular (LV) mass (available only in African-Americans). Generalized estimating equations were used to assess whether plasma MR-proANP was associated with measurements of target organ damage, independent of potential confounding variables. In African-Americans, higher MR-proANP was significantly associated with lower ABI (p <0.0001), higher UACR (p <0.0001), and greater LV mass (indexed to height to the power of 2.7, p <0.0001). After adjustment for age, gender, body mass index, systolic blood pressure, estimated glomerular filtration rate, smoking history, diabetes mellitus, total and high-density lipoprotein cholesterols, medication (blood pressure lowering, statin, and aspirin) use, and previous myocardial infarction or stroke, higher MR-proANP levels remained significantly associated with lower ABI (p = 0.01), higher UACR (p = 0.0007), and greater LV mass index (p <0.0001). In non-Hispanic whites, higher MR-proANP levels were significantly associated with lower ABI (p = 0.002) and greater UACR (p = 0.001), but not after adjustment for the covariates listed earlier. In conclusion, plasma MR-proANP may be a marker of target organ damage in the setting of hypertension, especially in African-Americans.

Association of C-reactive protein and microalbuminuria (from the National Health and Nutrition Examination Surveys, 1999 to 2004)

Chronic kidney disease and cardiovascular disease share many risk factors. Injury to the vascular endothelium, measured by elevated levels of serum C-reactive protein (CRP), may play a role in kidney and cardiovascular disease. We therefore examined the association of CRP with microalbuminuria, a marker of early kidney injury. We conducted a cross-sectional analysis of a nationally representative, population-based survey. Weighted multiple logistic regression was used to study the association between CRP and microalbuminuria, adjusting for well-known risk factors. CRP was analyzed by a continuous variable and two categorized variables using quartiles and clinically recommended cutpoints. CRP concentration was positively associated with microalbuminuria. In the multivariate model, a one unit (in milligrams per liter) increase in CRP concentration was associated with a 2% increased odds of microalbuminuria (odds ratio 1.02, 95% confidence interval [CI] 1.01 to 1.02, p=0.0003). When CRP concentrations were stratified by clinically recommended cutpoints, compared with persons with CRP concentrations<1 mg/dl, persons with CRP concentrations between 1 and 3 mg/L and >3 mg/L were 1.15 times (95% CI 0.94 to 1.42) and 1.33 times (95% CI 1.08 to 1.65) more likely to have microalbuminuria, respectively. In subgroup analyses, the strength of association was comparable or stronger. In conclusion, elevated CRP levels were associated with microalbuminuria in a large, nationally representative data set. Vascular inflammation, as measured by CRP, may be a common contributor to early heart and kidney disease.

Atrial natriuretic peptide increases urinary albumin excretion in people with normoalbuminuric type-2 diabetes

BACKGROUND

Atrial natriuretic peptide (ANP) is elevated in patients with type-2 diabetes and microalbuminuria. The purpose of this study is to evaluate if ANP increases Urinary Albumin Eaxcretion Rate (UAER) in type-2 diabetes.

METHODS

Eight normoalbuminuric diabetic subjects underwent a randomised single blind study of 60 min intravenous infusion of ANP or vehicle. Eight non-diabetic controls underwent ANP infusion alone. Seven normoalbuminuric type-2 diabetes subjects received further ANP infusions during euglycaemia and during hyperglycaemia.

RESULTS

ANP increased urinary sodium (191.3 +/- 80.7 to 529.2 +/- 263.4 mumol/min, mean +/- SD, and P < 0.001) and UAER (72.2 +/- 73.4 to 224.9 +/- 182.9.5 mug/min, and P < 0.01) in diabetic subjects. In controls, UAER did not change significantly (P = 0.16); however, the natriuretic response to ANP was similar to diabetic subjects (P = 0.98). Hyperglycaemic did not enhance the albuminuric response to ANP (P = 0.88).

CONCLUSION

ANP increases UAER in normoalbuminuric type-2 diabetic subjects.

Elevated plasma concentrations of atrial and brain natriuretic peptide in type 1 diabetic subjects

BACKGROUND

The intravenous infusion of atrial (ANP) and brain (BNP) natriuretic peptides have been shown to increase urinary albumin excretion in type 1 diabetes.

AIMS

To measure plasma ANP and BNP concentrations in patients with type 1 diabetes and to examine the parameters associated with elevated plasma concentrations. Methods We measured plasma ANP and BNP concentrations, UAER, HbA1C systolic blood pressure, and left ventricular mass index. Plasma ANP and BNP were also measured in non-diabetic control subjects for comparison.

RESULTS

Using multivariate regression analysis plasma ANP correlated positively with HbA1C (1.9 + 0.47, p = 0.0002), UAER (0.37 + 0.05, p = 0.00001), SBP (1.26 + 0.5, p = 0.01) and LVMI (00.46 + 0.25, p = 0.07). BNP was positively related with LVMI (0.95 + 0.4, p = 0.02), and UAER (0.56 + 0.08, p = 0.001).

CONCLUSIONS

Plasma concentrations of ANP and BNP are elevated in some patients with type 1 diabetes. Plasma ANP concentrations are closely related to UAER and elevated plasma concentrations are associated with poor glycaemic control and systemic hypertension. Plasma BNP concentration is related to LVMI.

Glomerular hyperfiltration in type 1 diabetes mellitus results from primary changes in proximal tubular sodium handling without changes in volume expansion

BACKGROUND

Glomerular hyperfiltration plays a role in the pathophysiology of diabetic nephropathy. An increase in the glomerular filtration rate (GFR) could result from primary actions at the glomerular/vascular level or could be the consequence of a primary increase in proximal tubular sodium reabsorption resulting in systemic volume expansion. Recently it was hypothesized that an increase in sodium reabsorption may lead to glomerular hyperfiltration through the tubulo-glomerular feedback mechanism (tubular-hypothesis) without volume expansion.

DESIGN

We have studied 54 normoalbuminuric patients with type 1 diabetes. The GFR was measured by inulin clearance. Proximal and distal sodium reabsorption were calculated according to standard formulas using the free water clearance technique. Plasma volume, measured by the (125)I-albumin method, atrial natriuretic peptide (ANP) and the second messenger cyclic guanosine-3,5-monophosphate (c-GMP) were used as markers of extracellular volume expansion.

RESULTS

Glomerular hyperfiltration (GFR >or= 130 mL min(-1) 1.73 m(-2)) was present in 14 out of 55 patients with diabetes (25%). There were no differences in plasma volume between normo-(NF) and hyper-filtrating (HF) patients (2933 +/- 423 in NF vs. 3026 +/- 562 mL in HF, NS). Also plasma ANP and c-GMP levels were not significantly different between the groups. The fractional proximal reabsorption of sodium was significantly increased in HF [fPRNa(+) (%) 90.1 +/- 2.0 vs. 91.5 +/- 1.6, P = 0.02]. There were no differences in distal sodium reabsorption or distal sodium load (approximately macula densa concentration of NaCl) in both groups.

CONCLUSIONS

Our data suggest that the primary event in diabetic glomerular hyperfiltration is an increase in proximal tubular sodium reabsorption. They do not support the hypothesis that systemic volume expansion or ANP mediate glomerular hyperfiltration in patients with normoalbuminuric type 1 diabetes. As such, changes in tubular sodium handling most probably influence tubulo-glomerular feedback.

New insights into the significance of microalbuminuria

PURPOSE OF REVIEW

This review summarizes recent work that has explored the association between microalbuminuria and adverse clinical outcomes in the presence and absence of diabetes.

RECENT FINDINGS

Recent investigations have documented the prevalence of microalbuminuria in the general community and have also highlighted the continuous relationship between the level of urinary albumin excretion and clinical endpoints. Even below traditional microalbuminuria thresholds, urinary albumin levels appear to correlate with clinical outcomes. Microalbuminuria is becoming increasingly recognized as an independent risk factor for cardiovascular morbidity and mortality. At least for subjects with type 2 diabetes and microalbuminuria, intensive, multifactorial interventions can reduce the risk of cardiovascular events by about 50%. Although several studies have found an association between microalbuminuria and surrogate measurements of vascular disease, the exact molecular mechanisms linking an increase in urinary albumin excretion and vascular disease are still unknown. Microalbuminuria also has a well-documented association with progressive diabetic renal disease but recent studies have suggested that the prognostic significance of microalbuminuria in this regard may not be as powerful as originally reported.

SUMMARY

Aggressive, multifactorial interventions, including the use of drugs that interrupt the renin-angiotensin system are strongly recommended for patients with diabetes and micro-albuminuria to ameliorate the progression of renal and vascular complications. This approach should also possibly apply to microalbuminuric subjects without diabetes. The relationship between microalbuminuria and progressive diabetic renal disease requires re-evaluation given temporal trends in the prevention and treatment of diabetic complications.