![]() Additionally, intensive glycemic control, optimization of blood pressure (BP), and the use of renal protective drugs, can slow or stop progression of diabetic nephropathy. eGFR, urinary albumin levels) do not always correlate well with the severity of renal disease seen on biopsy (17). It is important to note that the rate of progression can vary between individuals, and that the clinical markers of the disease (i.e. Thus, significant renal dysfunction is not usually seen until late in the course of diabetic nephropathy (16). However, late in the overt kidney disease phase, the rate of decline of renal function can accelerate (5 to 10 mL/min/1.73 m 2/year). During the early stages of diabetic nephropathy, the rate of loss of renal function is relatively slow (a decrease in eGFR of 1 to 2 mL/min/1.73 m 2/year), and not impressively higher than what is seen in the general population (0.5 to 1.0 mL/min/1.73 m 2/year) (15). The rate of progression from normoalbuminuria to microalbuminuria, then to overt kidney disease, is usually slow, typically taking five years or longer to progress through each stage (13,14). Over time, albuminuria can worsen so that the urinary albumin excretion is sufficiently high to be detectable by a urine dipstick, a stage known as “overt nephropathy” ( Table 1 ). This stage is referred to as “microalbuminuria”. Initially, small amounts of albumin are leaked, below the detection threshold of a urine dipstick. ![]() Persistent albuminuria is considered the earliest clinical sign of diabetic nephropathy. Identification of hyperfiltration is not clinically useful, as it is difficult to determine from routine testing and is not present in all people with early diabetic nephropathy. The earliest stage of diabetic nephropathy is hyperfiltration, where the glomerular filtration rate (GFR) is significantly higher than normal. Many of these risk factors are modifiable. Key risk factors include long duration of diabetes non-optimal glycemic, blood pressure and plasma lipid control obesity (11) and cigarette smoking (12). The classical description of diabetic nephropathy is a slow and progressive increase in albuminuria, followed later in the disease by a decrease in estimated glomerular filtration rate (eGFR) below 60 mL/min/1.73 m 2, which can, eventually, lead to end stage renal disease (ESRD) (1,9,10) ( Figure 2 ).
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