Microalbuminuria: a marker to increased renal and cardiovascular risk in diabetes mellitus

Role of Microalbuminuria and Hypoalbuminemia as Outcome Predictors in Critically Ill Patients

Background

Assessment of microalbuminuria and hypoalbuminemia can be used as a good tool for the prediction of the ICU outcome in critically ill patients.

Purpose

To evaluate and compare the prognostic significance of microalbuminuria (albumin creatinine ratio (ACR)) and serum albumin level done on admission and after twenty-four hours for the critically ill patients. Methodology. Sixty ICU patients were involved in a prospective cohort study (mean age was 44.4 ± 16.7 years, and 78.3% were males). Patients were divided into 2 groups according to mortality (survivors and nonsurvivors) and were subjected to laboratory measurement of the mentioned biomarkers on admission and after twenty-four hours.

Results

There were 34 patients (56.67%) in group A (survivors) and 26 patients (43.33%) in group B (nonsurvivors). Albumin creatinine ratio on admission (ACR1) and albumin creatinine ratio after 24 hours (ACR2) were significantly lower in survivors than nonsurvivors (P values were <0.001 for both). Serum albumin level after 24 hours of admission was significantly higher in survivors than nonsurvivors (P value 0.02) while admission serum albumin was not significantly different between both groups (P value was 0.1). There was a positive correlation between ACR2 and ICU stay and mechanical ventilatory support with a strong positive correlation with the use of vasopressor therapy (r: 0.35, 0.58, and 0.73, respectively). P values were 0.005, <0.0001, and <0.0001, respectively. There was a positive correlation between ACR2 with APACHE II and SOFA scores (r: 0.46 and 0.43, respectively); P values were 0.001 and <0.0001, respectively. There was a moderate negative correlation between serum albumin on admission and after 24 hours and the duration of mechanical ventilation (r: −0.4 and −0.39, respectively) (P values were 0.001 and 0.002, respectively). By Cox regression analysis, two parameters were found to be an independent predictor of mortality in ICU patients which were age and using vasopressor treatment (P values = 0.01 and <0.001), while the other parameters were not independent predictors of mortality (P values were more than 0.05).

Conclusions

Microalbuminuria on admission and after 24 hours of ICU admission could be a good predictor of mortality in critically ill patients. The serum albumin level after 24 hours of admission can predict poor outcomes in critically ill patients.

Type 2 diabetes mellitus management in patients with chronic kidney disease: an update

Diabetes mellitus (DM) is a chronic multisystem disease. Diabetic nephropathy (DN) is one of its significant microvascular complications, associated with increased morbidity and mortality. The aim of this article is to review the literature regarding the latest advances in the management of type 2 DM (T2DM) in patients with chronic kidney disease (CKD). We initially refer to the screening guidelines, the diagnostic tests used, the need for novel biomarkers in DN, the recent advances in high-risk patient identification, the recommended glycemic targets, and concerns regarding the accuracy of HbA1c in these patients. Then, a detailed explanation of the appropriate medical management based on evidence from recent trials is presented, analyzed, and discussed. All patients with T2DM should be screened for albuminuria at initial diagnosis and annually thereafter. Proteomics and metabolomics today represent promising diagnostic tools. Optimal glycemic control, with individualized HbA1c targets, is fundamental for reduced onset or delayed progression of DN and microvascular complications, in general. This can be enhanced by lifestyle modifications and pharmacological interventions when needed. Metformin represents the first pharmacological step, with, recently, a broadened indication for patients with impaired renal function. If HbA1c remains above the target in patients with established CKD, SGLT2i or GLP-1 RA are the preferred second-line agents, as introduced in all new guidelines. This change was the result of recent landmark trials that highlighted the superiority of the two aforementioned medication categories in terms of both renal and cardiovascular outcomes.

Association between Brachial-Ankle Pulse Wave Velocity and Microalbuminuria and to Predict the Risk for the Development of Microalbuminuria Using Brachial-Ankle Pulse Wave Velocity Measurement in Type 2 Diabetes Mellitus Patients

Brachial-ankle pulse wave velocity (baPWV) provides a useful means of assessing cardiovascular events and diabetic complications. However, the nature of associations between baPWV and microalbuminuria (MAU) and its presence in Type 2 diabetes mellitus (Type 2 DM) have rarely been investigated. This study aimed to examine the association between baPWV and MAU coupled with prediction of MAU using baPWV measurement among Type 2 DM patients. In this cross-sectional study, we enrolled 424 Type 2 DM patients who visited the cardiology and endocrinology department at a tertiary level health care facility, Republic of Korea between 1 January 2006 to 31 December 2008. Clinical and laboratory data were collected, and risk factors associated with MAU and prediction of risk for the development of MAU using baPWV measurement. The association between MAU and baPWV was examined using multivariable logistic regression analysis and predicted MAU by using receiver operating characteristic (ROC) curve analysis. Of the 424 Type 2 DM patients, 93 (21.9%) had MAU (20-200 μg/min). baPWV (cm/sec) was found to be significantly correlated with MAU levels (ug/min) (r = 0.791, p < 0.001). Further, baPWV was significantly associated MAU with higher odds ratio (adjusted odds ratio (AOR) 10.899; 95% confidence interval (CI) (4.518-26.292)). Similarly, smoking (AOR 10.899; 95% CI (4.518-26.292)), and low-density lipoprotein (LDL)-cholesterol (mg/dL) (AOR 1.017; 95% CI (1.001-1.033)) were also significantly associated with MAU. The appropriate cut-off value for baPWV to predict MAU 20 μg/min in our study was 1700 cm/sec (area under ROC curve = 0.976). This study shows that baPWV, cigarette smoking, and LDL-cholesterol are associated with MAU in Type 2 DM patients and suggests that a baPWV cut-off of 1700 cm/sec could be used to predict the presence of MAU (20 μg/min) in Type 2 DM patients in the Korean community.

Renal function and choroidal thickness using swept-source optical coherence tomography in diabetic patients

AIM

To assess the relationship between choroidal thickness and renal function in diabetic patients.

METHODS

Cross-sectional retrospective clinical study of 42 eyes of 21 ocular treatment-naïve diabetic patients. Demographic data included: age, sex, type and course of diabetes. Ocular data included: severity of diabetic retinopathy; retinal thickness at the central macular region, as well as choroidal thickness at the central and paracentral quadrants, using automatically generated maps by swept-source optical coherence tomography; presence of cystic macular edema; and ocular axial length (AXL). Lab-test parameters included: glycated hemoglobin (HbA1c), albuminuria, albumin/creatinine ratio in urine, and glomerular filtration rate.

RESULTS

A significant negative correlation was mainly observed between several choroidal thicknesses, age (P<0.020) and ocular AXL (P<0.030). On the contrary, a significant positive correlation was found between all choroidal thicknesses, HbA1c (P<0.035) and albuminuria (P<0.040).

CONCLUSION

Choroidal thickness can represent an additional tool to help clinicians predicting the renal status in ocular treatment-naïve diabetic patients.

Evaluation of the URiSCAN 2 ACR Strip to estimate the urine albumin/creatinine ratios

BACKGROUND

The urine albumin/creatinine ratio (ACR) test is used to screen patients with chronic diseases, such as diabetes, hypertension and cardiovascular diseases that put them at an increased risk of developing kidney disease. Here, we evaluated the performance of the URiSCAN 2 ACR Strip (URiSCAN; YD diagnostics, Yongin, Korea), a semiquantitative point-of-care testing (POCT) assay, and we compared to an existing POCT assay and a quantitative assay.

MATERIALS AND METHODS

A total of 1,020 random urine specimens were analyzed using the semiquantitative URiSCAN 2 ACR Strip and semiquantitative CLINITEK Microalbumin 2 Strip (CLINITEK; Siemens, New York, USA). We evaluated the precision of the URiSCAN 2 ACR Strip and compared the results of the ACR obtained from URiSCAN to those of CLINITEK with the quantitative results of a quantitative assay as a reference.

RESULTS

The precision evaluation of the URiSCAN revealed a range between the cutoff (C50 )-20% and C50 +20% bounds, the C5 -C95 interval, with 85.8% confidence. URiSCAN and CLINITEK showed sensitivity and specificity of 87.7% and 72.2%, and 90.2% and 83.0%, respectively. The concordance rates of URiSCAN with CLINITEK and the quantitative assay were 75.6% and 79.1%, respectively. The concordance rate in the abnormal range (≥30 mg/g) between URiSCAN and the quantitative assay were higher than that between CLINITEK and the quantitative assay (78.8% vs 75.4%).

CONCLUSIONS

URiSCAN showed good precision and comparable sensitivity with lower specificity than those of CLINITEK.

Urinary liver-type fatty acid binding protein is an independent predictor of stroke and mortality in individuals with type 1 diabetes

AIMS/HYPOTHESIS

In type 1 diabetes, cardiovascular disease (CVD) and diabetic nephropathy progress in parallel, thereby potentiating the risk of premature death during their development. Since urinary liver-type fatty acid binding protein (L-FABP) predicts the progression of diabetic nephropathy, the aim of this study was to investigate whether urinary L-FABP also predicts cardiovascular outcomes and mortality.

METHODS

We tested our hypothesis in a Finnish cohort of 2329 individuals with type 1 diabetes and a median follow-up of 14.1 years. The L-FABP to creatinine ratio was determined from baseline urine samples. The predictive value of urinary L-FABP was evaluated using Cox regression models, while its added predictive benefit for cardiovascular outcomes and mortality was evaluated using a panel of statistical indexes.

RESULTS

Urinary L-FABP predicted incident stroke independently of traditional risk factors (HR 1.33 [95% CI 1.20, 1.49]) and after further adjustment for eGFR (HR 1.28 [95% CI 1.14, 1.44]) or AER (HR 1.24 [95% CI 1.06, 1.44]). In addition, it predicted mortality independently of traditional risk factors (HR 1.34 [95% CI 1.24, 1.45]), and after adjustment for eGFR (HR 1.29 [95% CI 1.18, 1.39]) or AER (HR 1.22 [95% CI 1.09, 1.36]). Urinary L-FABP was as good a predictor as eGFR or AER, and improved the AUC for both outcomes on top of traditional risk factors, with no reclassification benefit (integrated discrimination improvement/net reclassification improvement) for stroke or mortality when AER or eGFR were added to traditional risk factors. However, urinary L-FABP was not a predictor of other cardiovascular endpoints (coronary artery disease, peripheral vascular disease and overall CVD events) when adjusted for the AER.

CONCLUSIONS/INTERPRETATION

Urinary L-FABP is an independent predictor of stroke and mortality in individuals with type 1 diabetes.

Renal function trajectory over time and adverse clinical outcomes

The growing burden of chronic kidney disease (CKD), with its associated morbidity and mortality, is recognized as a major public health problem globally and causing substantial load on health care systems. The current framework for the definition and staging of CKD, based on eGFR levels or presence of kidney damage, is useful for clinical classification of patients, but identifies a huge number of people as having CKD which is too many to target for intervention. The ability to identify a subset of patients, at high risk for adverse outcomes, would be useful to inform clinical management. The current staging system applies static definitions of kidney function that fail to capture the dynamic nature of the kidney disease over time. Now-a-days, it is possible to capture multiple measurements of different laboratory test results for an individual including eGFR values. A new possibility for identifying individuals at higher risk of adverse outcomes is being explored through assessment and consideration of the rate of change in kidney function over time, and this approach will be feasible in the current context of digitalization of health record keeping system. On the basis of the existing evidence, this paper summarizes important findings that support the concept of dynamic changes in kidney function over time, and discusses how the magnitude of these changes affect the future adverse outcomes of kidney disease, particularly the End Stage Renal Disease (ESRD), CVD and mortality.

Urinary Biomarkers in the Assessment of Early Diabetic Nephropathy

Diabetic nephropathy (DN) is a frequent and severe complication of diabetes mellitus (DM). Its diagnosis in incipient stages may allow prompt interventions and an improved prognosis. Towards this aim, biomarkers for detecting early DN can be used. Microalbuminuria has been proven a remarkably useful biomarker, being used for diagnosis of DN, for assessing its associated condition-mainly cardiovascular ones-and for monitoring its progression. New researches are pointing that some of these biomarkers (i.e., glomerular, tubular, inflammation markers, and biomarkers of oxidative stress) precede albuminuria in some patients. However, their usefulness is widely debated in the literature and has not yet led to the validation of a new "gold standard" biomarker for the early diagnosis of DN. Currently, microalbuminuria is an important biomarker for both glomerular and tubular injury. Other glomerular biomarkers (transferrin and ceruloplasmin) are under evaluation. Tubular biomarkers in DN seem to be of a paramount importance in the early diagnosis of DN since tubular lesions occur early. Additionally, biomarkers of inflammation, oxidative stress, podocyte biomarkers, and vascular biomarkers have been employed for assessing early DN. The purpose of this review is to provide an overview of the current biomarkers used for the diagnosis of early DN.

Is IL-33 useful to detect early stage of renal failure?

IL-33 is a proinflammatory cytokine that is a member of IL-1 family. Previously the effect of IL-33 on kidney injury is showed in animal models. In this study, we searched if we can use IL-33 to show the early stage of kidney injury in diabetic patients. Three groups are identified: 26 patients in Group 1: Healthy group, that do not have any chronic diseases and not taking any medication; 42 patients in Group 2: DM (diabetes mellitus) group without any known kidney disease and with normal kidney functions; 32 patients in Group 3: DM + MA (microalbuminuria) group that are assumed to have nephropathy. IL-33 level of DM patient group is greater than healthy group; also IL-33 level of DM + MA patient group is greater than healthy group; but there is not any difference between DM and DM + MA group. The increase in IL-33 levels in diabetic nephropathy is not associated with kidney injury but the increase could be resulting because of diabetes. So IL-33 cannot be used in early recognition of diabetic nephropathy.

Chronic kidney disease Markov model comparing paricalcitol to calcitriol for secondary hyperparathyroidism: a US perspective

OBJECTIVE

The objective of this study was to determine the cost effectiveness of paricalcitol versus calcitriol for the treatment of secondary hyperparathyroidism in patients with chronic kidney disease in the United States setting.

METHODS

A Markov process model was developed employing data sources from the published literature, paricalcitol clinical trials and observational studies, official US price/tariff lists and national population statistics. The comparator was calcitriol, a non-selective vitamin D receptor activator (VDRA) medication. The primary perspective of the study was that of the third-party payer in the US. The efficacy outcomes (reduction in secondary hyperparathyroidism (SHPT), reduction in proteinuria, complications and mortality) were extrapolated to: number of life-years gained (LYG) and number of quality-adjusted life-years (QALYs). Clinical and economic outcomes were discounted at 3.5%.

RESULTS

The reference case analysis was a 10-year time horizon based on a comparison of paricalcitol with calcitriol, which is started in chronic kidney disease (CKD) stage 3 and continued in CKD stage 4 and CKD stage 5. The use of paricalcitol leads to a cost saving of US$1941. The inclusion of indirect costs leads to a cost saving of US$2528. The use of paricalcitol leads to an increase in life-years gained (0.47 years) and a gain in QALYs (0.43). The use of paricalcitol results in a dominant outcome from the perspective of the third-party payer, as well as from the societal perspective. One-way sensitivity analyses and probabilistic sensitivity analyses confirmed the robustness of the model.

CONCLUSION

This model showed that the favorable clinical benefit of paricalcitol results in positive short and long-term health economic benefits. This study suggests that the use of paricalcitol in patients with early chronic kidney disease may be cost-effective from the third-party payer perspective in the US versus calcitriol. Additional comparative studies are necessary to validate these results.

Measuring the Quality of Care of Diabetic Patients at the Specialist Outpatient Clinics in Public Hospitals in Singapore

Introduction: This study aims to measure the quality of care for patients with diabetes mellitus at selected Specialist Outpatient Clinics (SOCs) in the National Healthcare Group. Materials and Methods: The cross-sectional study reviewed case-records of patients from 6 medical specialties who were on continuous care for a minimum of 15 months from October 2003 to April 2005. Disproportionate sampling of 60 patients from each specialty, excluding those co-managed by Diabetes Centres or primary care clinics for diabetes, was carried out. Information on demographic characteristics, process indicators and intermediate outcomes were collected and the adherence rate for each process indicator compared across specialties. Data analysis was carried out using SPSS version 13.0. Results: A total of 575 cases were studied. The average rate for 9 process indicators by specialty ranged from 47.8% to 70.0%, with blood pressure measurement consistently high across all specialties (98.4%). There was significant variation (P <0.001) in rates across the specialties for 8 process indicators; HbA1c, serum creatinine and lipid profile tests were over 75%, while the rest were below 50%. The mean HbA1c was 7.3% ± 1.5%. “Optimal” control of HbA1c was achieved in 51.2% of patients, while 50.6% of the patients achieved “optimal” low-density lipoprotein (LDL)-cholesterol control. However, 47.3% of patients had “poor” blood pressure control. Adherence to process indicators was not associated with good intermediate outcomes. Conclusions: There was large variance in the adherence rate of process and clinical outcome indicators across specialties, which could be improved further. Key words: Assessment, Indicators, Outcome, Process

Treatment of hypertension in patients with diabetes mellitus

Antihypertensive treatment in diabetes mellitus, especially in diabetics known to have cardiac autonomic neuropathy, may have to consider the status of the autonomic nervous system. In diabetic subjects with cardiac autonomic neuropathy, vagal activity during the night is often reduced. The reduction results in relative or absolute sympathetic activation, which could increase cardiovascular risk. Pathophysiological and clinical data suggests that antihypertensive treatment should reduce rather than induce sympathetic activity in this setting. Beta blocking agents, ACE inhibitors, calcium antagonists of verapamil or diltiazem type and selective imidazoline receptor agonists reduce sympathetic activity and, therefore, may have a beneficial effect in diabetic patients with disturbed sympathovagal balance.

Efeitos fisiológicos do treinamento físico em pacientes portadores de diabetes tipo 1

Insulinoterapia, atividade física regular e planejamento alimentar, em conjunto, consistem na abordagem mais completa no tratamento de portadores de diabetes mellitus tipo 1 (DM1). Estudos clínicos e experimentais têm evidenciado os benefícios do treinamento físico em indivíduos com DM1, tais como melhora na sensibilidade à insulina, redução das doses de insulina e atenuação das disfunções autonômicas e cardiovasculares. Essa revisão aborda as adaptações fisiológicas ao treinamento físico no indivíduo com DM1 e discute as recomendações e prescrição de atividade física para esta população.

Effects of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and their combination on microalbuminuria in normotensive patients with type 2 diabetes

The goal of this study was to compare the effects of lisinopril, losartan, and their combination on microalbuminuria in normotensive patients with type 2 diabetes mellitus. Patients were randomly assigned to 3 groups: group 1 (n=9), group 2 (n=9), and group 3 (n=8) received 10 mg lisinopril, 50 mg losartan, and 10 mg lisinopril plus 50 mg losartan, respectively, each day. For 12 mo, the 24-h urine albumin excretion rate was assessed at 3-mo intervals. At study completion, the urine albumin excretion rate had been reduced significantly in each group (P=.001); however, no significant differences were noted among groups (P=.587). Investigators in the present study have concluded that lisinopril, losartan, and their combination have similar effects on microalbuminuria in normotensive patients with type 2 diabetes mellitus, and that combination therapy does not provide additional benefit.

Cost-effective strategies in the prevention of diabetic nephropathy

A significant subgroup of patients with diabetes mellitus are predisposed to developing diabetic nephropathy and it is in this subgroup that other diabetes- related complications, and in particular greatly increased cardiovascular disease risk, are concentrated. The high personal, social and financial costs of managing end-stage renal failure and the other complications associated with diabetic nephropathy make a powerful case for screening and effective intervention programmes to prevent the condition or retard its progression. As major breakthroughs in finding genetic susceptibility factors remain elusive, screening efforts continue to be based on microalbuminuria testing, despite increasing recognition of its limitations as a positive predictor of nephropathy. Interventions have been extensively studied, but results remain conflicting. Economic evaluations of such screening and intervention programmes are essential for health planners, yet models of the cost/benefit ratio of such interventions often rely on a rather slim evidence base. Where economic models are developed, they are frequently based on those papers that propound the greatest clinical benefits of a given intervention, leading to a possible over-estimation of the advantages of the chosen approach. Furthermore, the benefits of even such generally accepted interventions as ACE inhibitor treatment are less firmly established than generally appreciated. Lifestyle interventions are instinctively attractive, but are by no means a low-cost option (as is often assumed by both medical professionals and politicians). This review critically assesses the evidence for clinical efficacy and economic benefit of microalbuminuria screening and interventions such as intensive glycaemic control, antihypertensive treatment, ACE inhibition and angiotensin receptor blockade, dietary protein restriction and lipid-modifying therapy. The various costs associated with diabetic nephropathy are so great that even expensive interventions may have a favourable cost/benefit ratio, provided they are truly effective.

Slowing the Progression of Adult Chronic Kidney Disease

When kidney disease of any aetiology results in substantial loss of nephrons, a common clinical syndrome, characterised by hypertension, proteinuria and a progressive decline in renal function, ensues. This observation suggests that common mechanisms may contribute to progressive renal injury and that therapeutic interventions that inhibit these common pathways may afford renal protection. Research to date has identified several mechanisms that may contribute to progressive renal injury including glomerular haemodynamic changes, multiple effects of angiotensin II and detrimental effects of excessive filtration of plasma proteins by injured glomeruli. Clinical trials over the past decade have identified several interventions that are effective in slowing the rate of progression of chronic kidney disease (CKD). The use of ACE inhibitors, angiotensin receptor antagonists or a combination of the two should be regarded as fundamental to any therapy for slowing the rate of CKD progression. Hypertension should be treated aggressively to achieve a blood pressure target of < 130/80 mm Hg. Reduction of proteinuria to < 0.5 g/day should be regarded as an independent therapeutic goal. Although inconclusive, there is some evidence to support moderate dietary protein restriction to 0.6 g/kg/day in appropriate patients. Hyperlipidaemia may contribute to CKD progression and should be treated to reduce cardiovascular risk and potentially improve renal protection. Smoking cessation should be encouraged and, where necessary, assisted. Among diabetic patients tight glycaemic control should be achieved (glycosylated haemoglobin < 7%). These interventions are simple and relatively inexpensive. If applied to all patients with CKD they will result in substantial slowing of renal function decline in many patients and thereby reduce the number who progress to end-stage renal disease and require renal replacement therapy.

Benefícios da atividade física no perfil lipídico de pacientes com diabetes tipo 1

Avaliamos a resposta do perfil lipídico a uma intervenção não-farmacológica de curta duração, e investigamos se alterações nas lipoproteínas estavam presentes, antes da nefropatia diabética (ND) clínica, em 46 pacientes jovens com diabetes tipo 1 (DM1), com idade de 15,5±1,5 anos submetidos a um programa de 8 dias de dieta apropriada e exercícios, durante controle glicêmico estável (glicemia média 110,3±27,1mg/dl e HbA1c 6,9±1,3%). No início, 65% dos jovens apresentavam colesterol total > 160mg/dl (IC 95% 0,51-0,78), enquanto que ao final somente 38% (IC 95% 0,24-0,51) tinham tais níveis. A melhora no perfil lipídico foi ainda melhor para a fração LDL, considerando que inicialmente 67% mostravam valores acima de 100mg/dl (IC 95% 0,55-0,78) e 24% (IC 95% 0,12-0,36) ao final. Valores de HDL-colesterol subnormais (< 40mg/dl) ocorreram em 38% (95% IC 0,24-0,51) e 11% (IC 95% 0,02-0,20) deles, no início e final do período. A razão albumina/creatinina média foi 9,0±8,0mg/g de creatinina. Encontramos fracas correlações entre a razão albumina/creatinina e os níveis de colesterol total (r= 0,21), LDL (r= 0,24), VLDL (r= 0,30), HDL (r= -0,17) e de triglicérides (r= 0,31). Dentro da faixa de referência de albuminúria, não foi encontrada nenhuma associação entre a excreção urinária de albumina e os níveis de lípides nos pacientes com DM1 estável. Um programa de exercícios regulares é eficaz em otimizar o perfil lipídico nestes pacientes, independentemente do controle glicêmico. Nossos dados não apoiam a hipótese de que mudanças no metabolismo lipídico precederiam a microalbuminúria no curso da ND.

Achieving maximal renal protection in nondiabetic chronic renal disease

A rapid global increase in the number of patients requiring renal replacement therapy necessitates that effective strategies for renal protection are developed and applied widely. We review the experimental and clinical evidence in support of individual renoprotective interventions, including angiotensin-converting enzyme therapy, control of systemic hypertension, dietary protein restriction, reduction of proteinuria, treatment of hyperlipidemia, and smoking cessation. We also consider potential future renoprotective therapies. To achieve maximal renal protection, a comprehensive strategy employing all of these elements is required. This strategy should be directed at normalizing clinical markers of renal disease to induce a state of remission.

Evolving strategies for renoprotection: non-diabetic chronic renal disease

Experimental and clinical studies over the past two decades have identified several interventions for slowing the progression of chronic renal disease towards end-stage renal failure. In this paper we review the experimental and clinical evidence in support of dietary protein restriction, angiotensin-converting enzyme inhibitor therapy, control of systemic hypertension, reduction of proteinuria, treatment of hyperlipidemia and smoking cessation. We also consider potential future renoprotective therapies. Finally we propose a comprehensive strategy for achieving maximal renoprotection with available interventions and monitoring.