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Detection and Management of Diabetic Glomerulopathy in Children and Adolescents with Insulin-Dependent Diabetes Mellitus: Need for Improved Knowledge and Better Care

Current modalities of detection and management of incipient diabetic nephropathy in childhood and adolescence are summarized and the open questions outlined. In particular, the predictive value of microalbuminuria for later nephropathy in adolescents is examined. Microalbuminuria is not as strong a predictor as suggested in earlier studies - recent studies show up to 50% of microalbuminuria can revert to normal. We advocate that the association of well-established risk markers and promoters of renal injury, including degree and tracking of albuminuria, glycemic control, blood pressure changes, incipient retinopathy and genetic background, allow more precise assessment of the individual risk of developing nephropathy and the decision to start pharmacological intervention. The major impact of strict glycemic control to prevent the development and progression of diabetic nephropathy is emphasized, as well as the need for a multidisciplinary team to optimize the care of pediatric diabetic patients. We discuss other therapeutic options, i.e. angiotensin-converting enzyme inhibitors (ACE-Is), moderate dietary protein intake, and other drugs. ACE-Is may provide a second line intervention in a well selected, high-risk subgroup of microalbuminuric diabetic adolescents.