LAUSR

A few years ago, we started finding, for the first time, expressions such as “histologic reversibility,” or “change in the natural history” referring to diabetic nephropathy (DN) – a hopeful surprise. Reports showed the reversibility of renal histopathologic changes in native kidneys after pancreatic transplantation and in renal grafts from diabetic donors after kidney transplantation [1, 2]. Also, the normalization of the classic clinical signs of DN like microalbuminuria has been described [3]. Taken together these data suggest that the earlier clinicopathologic findings of DN are dynamic, rather than irreparable, opening the door for the reversibility of the early stages of DN. This optimism was revitalized after the publication of a series of studies showing a potential delay in DN progression with new antidiabetic drugs, an effect that proved to be independent of the hypoglycemic effect [4, 5]. There is an optimistic mood in this field, as many believe that we are in a new era, in which for the first time we can act specifically in one of the early pathogenic paths of DN like glomerular hyperfiltration and increased tubular sodium reabsorption. Following the above, a better understanding of the pathogenesis, the natural history of DN (namely, the earliest stages), and the earliest clinical manifestations of the disease are of utmost importance – specifically when reversing the lesions and modifying the natural history of DN seem to be a reality [6]. In opposition to the beginning of the century, we now know that DN is not only a glomerular disease but also a tubular, interstitial, and vascular disease [7, 8]. With this in mind, the classic (but weak) clinical markers of glomerular lesions should be reinforced with new reliable markers able to mark the earliest histologic changes – not only glomerular [6–9]. Apart from the diabetes, amidst the changes in the metabolic syndrome, we should give more attention to renal lipotoxicity (analogous to the nonalcoholic fatty liver disease) and to childhood obesity and its impacts on the kidney. The ENBiBA project of the DIABESITY Working Group of the European Renal Association/European Dialysis and Transplantation Association was created to investigate the natural history of DN (namely, the different phenotypes of this disease) and specifically the early stages (not biopsied in the clinical everyday life) [10]. These issues constituted the main points discussed in the CME course sponsored by the DIABESITY Working Group of the European Renal Association/European Dialysis and Transplantation Association, which was held in Lisbon, Portugal, on November 24 and 25, 2017.