Therefore hypertension usually precedes the onset of microalbuminuria.3 BP control modulates see more the progression not only of microangiopathy (diabetic kidney disease and retinopathy) but also of macroangiopathy (Coronary heart disease (CHD) and

stroke). In microalbuminuric people with type 2 diabetes, observational studies have shown an association between poor glycaemic control and progression of albuminuria. A number of studies have identified a strong independent association between hyperglycaemia and the rate of development of microvascular complications.4 The large observational WESDR study5 indicated an exponential relationship between worsening glycaemic control and the incidence of nephropathy as well as retinopathy and neuropathy. The UKPDS has clearly shown the importance of targeting glycosylated haemoglobin (HbA1c) levels close to normal (HbA1c < 7.0%) in people with type 2 diabetes. A modest decrease in HbA1c over 10 years from 7.9 to 7.0% lowered the risk of microvascular endpoints

with the onset of microalbuminuria being reduced by 25%.6 These findings are supported by a study of intensified glycaemic control in non-obese Japanese BI6727 subjects with type 2 diabetes.7 In the UKPDS, there was no significant reduction in the risk of progression from microalbuminuria to proteinuria with intensive blood glucose control.8 The AusDiab study collected information on albuminuria, measured as a spot albumin: creatinine ratio (ACR) (mg/mmol) with microalbuminuria being between 3.4 and 34 mg/mmol and macroalbuminuria at >34 mg/mol.9 The prevalence of albuminuria increased with increasing glycaemia. People with diabetes and impaired glucose tolerance had an increased risk for albuminuria compared with those with normal glucose tolerance, independent of other known risk factors for albuminuria (including age and sex). Hyperglycaemia is an important determinant of the progression of normoalbuminuria to microalbuminuria in diabetes.

Buspirone HCl Strict blood glucose control has been shown to delay the progression from normoalbuminuria to microalbuminuria or overt kidney disease6 and from normo- or microalbuminuria to overt kidney disease.7 The influence of intensive glycaemic control is greatest in the early stages of CKD although some observational studies suggest an association of glycaemic control with the rate of progression of overt kidney disease and even end-stage kidney disease (ESKD).10 The American Heart Association (AHA) has undertaken a review of the DCCT, UKPDS, ACCORD, ADVANCE and VA Diabetes trials and on the basis of the review issued a Scientific Statement addressing intensive glycaemic control in relation to cardiovascular events.11 While the AHA review is focused on cardiovascular events, the statement is relevant to the consideration of the management of CKD given the strong association between CKD and CVD in people with type 2 diabetes.