When should ACE Inhibitors be given to normotensive patients with IDDM

Abstract

See page 1787 Recent clinical trials have shown that angiotensinconverting-enzyme (ACE) inhibitors have beneficial effects on progression of nephtropathy in patients with insulindependent diabetes mellitus (IDDM). In today’s Lancet the EUCLID trial, the largest of its kind to date, reports that an ACE inhibitor significantly reduced urinary albumin excretion (UAE) rate in normotensive IDDM patients. These studies have led to questions that include which IDDM patient should receive an ACE inhibitor and when an ACE inhibitor should be given. The indication for starting ACE inhibitors is clear if the patient also has raised blood pressure. But in normotensive patients what would be a rational approach? Several epidemiology studies published more than a decade ago showed that 30-40% of IDDM patients developed clinical evidence of diabetic nephropathy. Although the prevalence of diabetic nephropathy has been decreasing during the past 3 decades because of improving diabetic care, diabetic nephropathy still represents the leading cause of dialysis in the western world. Fortunately recent studies have yielded encouraging results, and an integrated strategy now can be developed to prevent progression of diabetic nephropathy. Since not every IDDM patient will develop severe diabetic nephropathy, ideally preventive measures such as ACE inhibitors should be given only to those IDDM patients who are at risk of developing overt nephropathy. But reliable and practical ways of identifying those normotensive patients with such high risk before the onset of nephropathy are not yet available. The alternative is to identify those normotensive IDDM patients who are at a very early stage of diabetic nephropathy and are likely to develop advanced nephropathy. UAE has emerged as the best marker and the most practical method for detection of early diabetic nephropathy, and the occurrence of persistent microalbuminuria predicts later development of renal failure in IDDM patients. 1