SummaryWe investigated the contribution of polymorphisms in the angiotensin II type 1 receptor gene (AGTR1) to renal complications in an inception cohort of 152 insulin-dependent diabetic (IDDM) patients examined 15-21 years after diabetes onset. This'nested case-control study included 79 normoalbuminuric control subjects and 73 cases with evidence of nephropathy ranging from microalbuminuria to overt proteinuria. Subjects were genotyped for two AGTR1 polymorphisms (T573----)C and Al166----~C), and an adjacent CA repeat microsatellite. Allele C 1166 and the 140 bp allele of the microsatellite were more frequent among nephropathy cases than normoalbuminuric control subjects (0.322 vs 0.247, and 0.618 vs 0.521, respectively), but these differences were not statistically significant. Although not significant by themselves, the AGTR! polymorphisms contributed significantly to the risk of diabetic nephropathy when accompanied by poor glycaemic control. Among patients with frequent severe hyperglycaemia during the first decade of diabetes, the relative risk of nephropathy among allele C 1166 carriers was 12.1 (95 % CI: 3.7-39.8), whereas it was only 1.4 (95 % CI: 0.6-3.5) among allele A 1166 homozygotes. The difference between relative risks was highly significant (Z 2 --8.25, p = 0.004 with 1 df). A similar pattern of higher risk of microalbuminuria, specifically among those carriers of allele C 1166 who had poor glycaemic control was also found in an independent study of a cross-sectional sample of 551 IDDM individuals, although the effect was smaller in magnitude. We conclude that DNA sequence differences in the AGTR1 gene may modify the noxious effects of hyperglycaemia on the kidney. Allele C 1166 carriers might especially benefit from nephropathy prevention programmes. [Diabetologia (1997[Diabetologia ( ) 40: 1293[Diabetologia ( -1299 Kel~ords Insulin-dependent diabetes mellitus, diabetic nephropathy, angiotensin II receptor, DNA polymorphisms, genetics.Less than half of the patients with insulin-dependent diabetes mellitus (IDDM) develop diabetic nephropathy, which represents the major predictor of morbidity and premature mortality among these individuals [1,2]. Why this complication develops in only a Received: 4 March 1997 and in revised form: 18 June 1997Corresponding author: A. S. Krolewski, M. D. Ph.D., Section on Epidemiotogy and Genetics, Joslin Diabetes Center, One Joslin Place, Boston, MA 02215, USA Abbreviations: IDDM, insulin-dependent diabetes mellitus; ACE, angiotensin converting enzyme; AER, albumin excretion rate; ACR, albumin creatinine ratio; DGGE, denaturing gradient gel electrophoresis subset of IDDM patients is not known. Poor glycaemic control has been recognized as a major determinant of renal complications in IDDM [3,4], but other factors, unrelated to hyperglycaemia, also appear to be operating. The recent finding of familial clustering of diabetic nephropathy suggests that renal complications in IDDM are the result of an interaction between the diabetic milieu and nephropathy predisposi...