-This study depicts the natural history of diabetic (type 2) nephropathy reminding us that the progression from mild CKD to ESRD is a
even in the absence of an ACEi or
-Thus, one need not uniformly prescribe an ACEi for the indication of diabetic nephropathy if the patient's life expectancy is shorter than the predicted time to end-stage renal disease
(e.g. the elderly with mild renal dysfunction). By administering ACEi/ARB on a case-by-case basis, acute kidney injury and other complications related to combined ACEi and diuretic therapy can be averted.
-Given the high prevalence of diabetic renal insufficiency, why do more patients not require dialysis? Over the course of the study, 12% required dialysis but another 12% expired, commonly from a cardiovascular (CV) event. BP and lipid management are therefore imperative in this population.
-Because of this CV burden, some believe that ACEi therapy is indicated for its cardio-protective effects in this group. However, I do not feel the evidence cited (HOPE trial) is sufficient to merit this broad recommendation.
-Study Limitations: Type 1 diabetics were not considered; declines in renal function are more gradual in the present era in which glycemic and BP targets are lower than those cited.
-Disclosures: I have no conflicts to declare.