Prevention of Diabetic Nephropathy in Children and Adolescents: How Effective are the Current Strategies?

This paper aims to review the risk factors for diabetic nephropathy (DN) and the effectiveness of the current strategies for its prevention. Type 1 diabetes mellitus (T1DM) is the predominant form of diabetes in children and adolescents, but the prevalence of Type 2 diabetes mellitus (T2DM) in these age groups is currently increasing worldwide. One of the major challenges of T1DM is the development of DN among other microvascular complications. DN evolves over a long period of time starting from microalbuminuria and progressing to end stage renal failure. While microalbuminuria in children is reversible and may not evolve to end-stage renal failure, macroalbuminuria inevitably progresses to end-stage renal failure irrespective of any known treatment. Several modifiable and non-modifiable risk factors are well documented in the literature but addressing a few are critical in the prevention of DN. For instance, tight glycemic control and intensive control of hypertension have significant impact on prevention and progression of DN. From several studies, tight glycemic control has been shown to decrease the risk of microvascular disease in both T1DM and T2DM. Thus, poor glycemic control is critical in the etiology of DN. While tight glycemic control in patients with T1DM reduces the incidence of microalbuminuria and the progression from microalbuminuria to macroalbuminuria, there is overwhelming evidence to show that antihypertensive treatment with angiotensin converting enzyme (ACE) inhibitors is important in both preventing and treating microalbuminuria, and thus preventing progression to overt DN. Dietary protein restriction is also an adjunct strategy in retarding the progression of DN. Other novel therapeutic strategies have been recently tried and found potentially effective. Research is ongoing to establish the clinical efficacy and usefulness of some of these new agents in futur