There are several pathologic processes that contribute to diabetic nephropathy, including glomerular hypertrophy, sclerosis and nephron loss (Walling 2000). In the beginning stage, hyperglycemia increases the glomerular filtration rate and causes glomerular hypertrophy, and is already established in 40 percent of patients at the time of diagnosis with diabetes (Walling 2000). The microalbuminuric stage develops roughly five years after diagnosis in patients with type 1 diabetes but may occur earlier in patients with type 2 diabetes (Walling 2000). Up to 300 mg of albumin may be excreted daily (Walling 2000). Good glycemic control and introduction of angiotensin-converting enzyme (ACE) inhibitors can retard progression of nephropathy at this stage, while at more advanced stages of diabetic nephropathy, overt proteinuria, hypertension and reduction in creati

Anemia may occur in patients with diabetic nephropathy even before the onset of advanced renal failure, and has been related to erythropoietin deficiency (Zelmanovitz 2005). Anemia is also considered a risk factor for progression of renal disease and retinopathy (Zelmanovitz 2005). It is recommended to start erythropoietin treatment when Hb levels are < 11 g/dl, and the target Hb levles should be 12-13 g/dl, and the potential risk of elevation of blood pressure levels with erythropoietin treatment should be taken into account (Zelmanovitz 2005).

According to a study published in the April 01, 2000 issue of Diabetes Care, blood pressure control of 138/86 or 132/78 mmHg with either nisoldipine or enalapril as the initial antihypertensive medication appeared to stabilize renal function in hypertensive type 2 diabetic patients without overt albuminuria over a 5-year period. The more intensive blood pressure control decreased all-cause mortality (Schrier 2000). The study revealed no difference between intensive versus moderate blood pressure control and enalpril versus nisoldipine with regard to the progression of diabetic retinopathy and neuropathy over 5 years (Schrier 2000). Although the study demonstrated no difference between the use of a CCB versus an ACE inhibitor with regard to microvascular complications, the use of an ACE inhibitor as the initial antihypertensive medication perhaps should be preferred because of its possible advantage in macrovascular complications (Schrier 2000).

Diabetic nephropathy is more prevalent among African Americans, Asians, and Native Americans than Caucasians (Zelmanovitz 2005). Moreover, among patients starting renal replacement therapy, the incidence of diabetic nephropathy doubled from 1991-2001, however the rate of increase has slowed down (Zelmanovitz 2005). The reason for the slow down is probably due to the adoption in clinical practice of several measures that contribute to the early diagnosis and prevention of diabetic nephropathy, which thereby decreases the progression of established renal disease (Zelmanovitz 2005). A ten-year follow-up revealed the risk of diabetic nephropathy was 29 times greater in patients with type 2 diabetes with UAE values > 10 (micro)g/min, and the same held true for patients with type 1 diabetes (Zelmanovitz 2005). This favors the concept that the risk associated with UAE is a continuum, as is the case with blood pressure levels (Zelmanovitz 2005).

Thus, these progression promoters can explain a part of the highly variable course of kidney function in the individual patients with diabetic nephropathy,

A 2000 study published in the May 01, 2000 issue of Diabetes revealed that a 12-week trandolapril treatment restored normal circadian BP variation in normoalbuminuric normotensive type 2 diabetes subjects without causing clinically overt hypotonia (Drzewoski 2000). Furthermore, normal nocturnal blood pressure fall was maintained 2 to 4 weeks after the discontinuation of the drug despite elevation in systolic and diastolic BP towards its pre-treatment values (Drzewoski 2000).

Or possibly, a metabolic neutral compound, carvedilol should be used (Zelmanovitz 2005). The combination of beta-blockers and nondihydropyridine calcium channel blockers should be used with caution, since both agents have negative chronotropic effects (Zelmanovitz 2005).

Some common words found in the essay are:
, Caucasians Zelmanovitz, Prevention Evaluation, UAE Zelmanovitz, Disease MDRD, Moreover UAE, Treatment HOT, zelmanovitz 2005, diabetic nephropathy, blood pressure, type 2, type 1, patients type, diabetic patients, ace inhibitors, walling 2000, thornalley 2003, type 2 diabetic, 2 diabetic patients, patients type 2, type 1 diabetes, type 2 diabetes,
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