Have we reached the limits for the treatment of diabetic nephropathy

Introduction: The prevalence of diabetic nephropathy is increasing as a consequence of the global epidemic of diabetes, and the complications of diabetic nephropathy are unsurprisingly legion. Blockade of the renin–angiotensin–aldosterone system (RAAS) has formed the mainstay of management, but despite this, most individuals will suffer premature cardiovascular events, and many will progress to end-stage renal disease. Given the heterogeneity of pathologies, it is perhaps naive to hope that blocking a single neurohormonal pathway will protect against the myriad of pathogenetic mechanisms that conspire to cause the injuries seen with diabetes. Chronic hyperglycaemia and resulting advanced glycation end products form a mechanistic axis, which appears central to many of the pathways that lead to diabetic nephropathy. Treatment with pyridoxamine (an inhibitor of advanced glycation end-products) may represent a strategy to counter these injurious pathways. Areas covered: In this review, the authors explore pyr...