End-state renal failure can be reduced by 50% >The rate of decline in renal function in patients starting dialysis can be almost halved in clinical practice. This is comparable to the major reductions achieved by interventions, especially blood pressure control, used in clinical trials.
Noting that diabetic nephropathy is the most common cause of end-stage renal failure in patients beginning dialysis, specialists at Glasgow Royal Infirmary, Glasgow, Scotland, studied demographic and laboratory data on 170 consecutive patients referred to a combined diabetic-renal clinic over the course of 10 years.
Median serum creatinine at referral was 170 µmol/l and exceeded 350 µmol/l in 26 percent of patients. Mean blood pressure was 159/85 mmHg. Guidelines by the Scottish Intercollegiate Guidelines Network recommending more active intervention and earlier referral had no impact on referral blood pressure and creatinine.
There were significant improvements in blood pressure, albuminuria, HbA1c and serum cholesterol in 125 patients after at least one-year follow-up. In 63 patients followed up for three years (median creatinine 120 µmol/l), the median rate of decline in renal function slowed significantly, from 0.52 ml/min/month in the first year to 0.27 ml/min/month in the third year, thus nearly doubling the time to end-stage renal failure.
The specialists observed that reducing the rate of progression to less than 0.25 ml/min/month in 70 percent of patients with diabetic nephropathy presenting with serum creatinine below 150 µmol/l would be "a challenging but achievable standard" for audit.
Quarterly Journal of Medicine 2002;95:41-49