Diabetic nephropathy in children and adolescents and its consequences in adults

Insulin dependent diabetes mellitus (IDDM) is a disease predominantly affecting children and young adults. Over the last few decades, there has been an increase in the number of patients with IDDM which has almost doubled the incidence per generation. Evidence suggests that autoimmunity plays an important role in its pathogenesis. Diabetic nephropathy is a serious complication of IDDM, affecting about one-third of patients. It is accompanied by generalized micro- and macroangiopathy, neuropathy and arterial hypertension. Diabetic nephropathy is characterized by a long evolution, starting from microalbuminuria and, over 10-20 years, leading to end stage renal failure (ESRD). Microalbuminuria in children is reversible and by no means necessitates evolution to ESRD. Conversely, overt albuminuria inevitably progresses to ESRD irrespective of any known treatment. The principal pathogenic factors of diabetic nephropathy are glucose metabolic derangement and genetic predisposition, but to date no definite candidate gene(s) have been established as predisposing to the disease. Once diabetic nephropathy is established, it carries a high risk of morbidity and mortality because of the concurrent occurrence of other functional abnormalities, some of them life-threatening. Hemodialysis, peritoneal dialysis and renal transplantation are effective treatments of ESRD due to diabetic nephropathy, but recurrence of the disease in the renal transplant is very common among patients with IDDM unless renal transplantation is accompanied bypancreatic transplantation.