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Matsuzaki K, Suzuki H, Kikuchi M, Koike K, Komatsu H, Takahashi K, Narita I, Okada H. Current treatment status of IgA nephropathy in Japan: a questionnaire survey. Clin Exp Nephrol 2023; 27:1032-1041. [PMID: 37646957 PMCID: PMC10654181 DOI: 10.1007/s10157-023-02396-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 08/11/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND In 2020, the Committee of Clinical Practical Guideline for IgA Nephropathy (IgAN) revised the clinical practice guidelines. Herein, we conducted a questionnaire survey to assess the potential discrepancies between clinical practice guidelines and real-world practice in Japan. METHODS A web-based survey of members of the Japanese Society of Nephrology was conducted between November 15 and December 28, 2021. RESULTS A total of 217 members (internal physicians: 203, pediatricians: 14) responded to the questionnaire. Of these respondents, 94.0% answered that the clinical practice guidelines were referred to "always" or "often." Approximately 66.4% respondents answered that histological grade (H-Grade) derived from the "Clinical Guidelines for IgA nephropathy in Japan, 3rd version" and the "Oxford classification" were used for pathological classification. Moreover, 73.7% respondents answered that the risk grade (R-grade) derived from the "Clinical Guidelines for IgA nephropathy in Japan, 3rd version" was referred to for risk stratification. The prescription rate of renin-angiotensin system blockers increased based on urinary protein levels (> 1.0 g/day: 88.6%, 0.5-1.0 g/day: 71.0%, < 0.5 g/day: 25.0%). Similarly, the prescription rate of corticosteroids increased according to proteinuria levels (> 1.0 g/day: 77.8%, 0.5-1.0 g/day: 52.8%, < 0.5 g/day: 11.9%). The respondents emphasized on hematuria when using corticosteroids. In cases of hematuria, the indication rate for corticosteroids was higher than in those without hematuria, even if the urinary protein level was 1 g/gCr or less. Few severe infectious diseases or serious deterioration in glycemic control were reported during corticosteroid use. CONCLUSION Our questionnaire survey revealed real-world aspects of IgAN treatment in Japan.
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Affiliation(s)
- K Matsuzaki
- Department of Public Health, Kitasato University School of Medicine, Kanagawa, Japan
| | - H Suzuki
- Department of Nephrology, Juntendo University Urayasu Hospital, Chiba, Japan.
| | - M Kikuchi
- Department of Nephrology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - K Koike
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - H Komatsu
- Center for Medical Education and Career Development, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - K Takahashi
- Department of Biomedical Molecular Sciences, Fujita Health University School of Medicine, Aichi, Japan
| | - I Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - H Okada
- Department of Nephrology, Saitama Medical University, Saitama, Japan
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Fulton EA, McBrearty AR, Shaw DJ, Ridyard AE. Response and survival of dogs with proteinuria (UPC > 2.0) treated with angiotensin converting enzyme inhibitors. J Vet Intern Med 2023; 37:2188-2199. [PMID: 37815154 PMCID: PMC10658551 DOI: 10.1111/jvim.16864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 08/24/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors (ACEi) are a recommended treatment for glomerular proteinuria. Frequency of response to ACEi and the association of achieving proposed urine protein-to-creatinine ratio (UPC) targets on survival is unknown. OBJECTIVES To determine response rates to ACEi therapy and whether a positive response is associated with improved survival. ANIMALS Eighty-five dogs with proteinuria (UPC > 2.0). METHODS Retrospective study including dogs (UPC > 2.0) prescribed an ACEi for treatment of proteinuria. Baseline creatinine, albumin, cholesterol, UPC, and systolic blood pressure were recorded, and cases reviewed to track UPC. Treatment response was defined as achieving a UPC of <0.5 or reduction of ≥50% from baseline within 3 months. Outcome data were collected to determine overall and 12-month survival. RESULTS Thirty-five (41%) dogs responded to ACEi treatment. Treatment response was statistically associated with both median survival time (664 days [95% confidence interval (CI): 459-869] for responders compared to 177 [95% CI: 131-223] for non-responders) and 12-month survival (79% responders alive compared to 28% non-responders). Baseline azotemia or hypoalbuminemia were also associated with a worse prognosis, with odds ratios of death at 12 months of 5.34 (CI: 1.85-17.32) and 4.51 (CI: 1.66-13.14), respectively. In the 25 dogs with normal baseline creatinine and albumin, response to treatment was associated with 12-month survival (92% responders alive compared to 54% non-responders, P = .04). CONCLUSIONS AND CLINICAL IMPORTANCE When the UPC is >2.0, achieving recommended UPC targets within 3 months appears to be associated with a significant survival benefit. Response to treatment is still associated with survival benefit in dogs with less severe disease (no azotemia or hypoalbuminemia).
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Affiliation(s)
- Emily A. Fulton
- The University of Glasgow Small Animal Hospital, School of Biodiversity, One Health and Veterinary Medicine, 464 Bearsden RoadGlasgow G61 1QHUnited Kingdom
| | - Alix R. McBrearty
- VetsNow Hospital Glasgow, 123‐145 North StreetGlasgow G3 7DAUnited Kingdom
| | - Darren J. Shaw
- Royal (Dick) School of Veterinary Studies, The University of Edinburgh, Easter Bush CampusRoslin EH25 9RGUnited Kingdom
| | - Alison E. Ridyard
- The University of Glasgow Small Animal Hospital, School of Biodiversity, One Health and Veterinary Medicine, 464 Bearsden RoadGlasgow G61 1QHUnited Kingdom
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3
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Cooper TE, Teng C, Tunnicliffe DJ, Cashmore BA, Strippoli GF. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for adults with early (stage 1 to 3) non-diabetic chronic kidney disease. Cochrane Database Syst Rev 2023; 7:CD007751. [PMID: 37466151 PMCID: PMC10355090 DOI: 10.1002/14651858.cd007751.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a long-term condition that occurs as a result of damage to the kidneys. Early recognition of CKD is becoming increasingly common due to widespread laboratory estimated glomerular filtration rate (eGFR) reporting, raised clinical awareness, and international adoption of the Kidney Disease Improving Global Outcomes (KDIGO) classifications. Early recognition and management of CKD affords the opportunity to prepare for progressive kidney impairment and impending kidney replacement therapy and for intervention to reduce the risk of progression and cardiovascular disease. Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) are two classes of antihypertensive drugs that act on the renin-angiotensin-aldosterone system. Beneficial effects of ACEi and ARB on kidney outcomes and survival in people with a wide range of severity of kidney impairment have been reported; however, their effectiveness in the subgroup of people with early CKD (stage 1 to 3) is less certain. This is an update of a review that was last published in 2011. OBJECTIVES To evaluate the benefits and harms of ACEi and ARB or both in the management of people with early (stage 1 to 3) CKD who do not have diabetes mellitus (DM). SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 6 July 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and Embase, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) reporting the effect of ACEi or ARB in people with early (stage 1 to 3) CKD who did not have DM were selected for inclusion. Only studies of at least four weeks duration were selected. Authors independently assessed the retrieved titles and abstracts and, where necessary, the full text to determine which satisfied the inclusion criteria. DATA COLLECTION AND ANALYSIS Data extraction was carried out by two authors independently, using a standard data extraction form. The methodological quality of included studies was assessed using the Cochrane risk of bias tool. Data entry was carried out by one author and cross-checked by another. When more than one study reported similar outcomes, data were pooled using the random-effects model. Heterogeneity was analysed using a Chi² test and the I² test. Results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach MAIN RESULTS: Six studies randomising 9379 participants with CKD stages 1 to 3 (without DM) met our inclusion criteria. Participants were adults with hypertension; 79% were male from China, Europe, Japan, and the USA. Treatment periods ranged from 12 weeks to three years. Overall, studies were judged to be at unclear or high risk of bias across all domains, and the quality of the evidence was poor, with GRADE rated as low or very low certainty. In low certainty evidence, ACEi (benazepril 10 mg or trandolapril 2 mg) compared to placebo may make little or no difference to death (any cause) (2 studies, 8873 participants): RR 2.00, 95% CI 0.26 to 15.37; I² = 76%), total cardiovascular events (2 studies, 8873 participants): RR 0.97, 95% CI 0.90 to 1.05; I² = 0%), cardiovascular-related death (2 studies, 8873 participants): RR 1.73, 95% CI 0.26 to 11.66; I² = 54%), stroke (2 studies, 8873 participants): RR 0.76, 95% CI 0.56 to 1.03; I² = 0%), myocardial infarction (2 studies, 8873 participants): RR 1.00, 95% CI 0.84 to 1.20; I² = 0%), and adverse events (2 studies, 8873 participants): RR 1.33, 95% CI 1.26 to 1.41; I² = 0%). It is uncertain whether ACEi (benazepril 10 mg or trandolapril 2 mg) compared to placebo reduces congestive heart failure (1 study, 8290 participants): RR 0.75, 95% CI 0.59 to 0.95) or transient ischaemic attack (1 study, 583 participants): RR 0.94, 95% CI 0.06 to 15.01; I² = 0%) because the certainty of the evidence is very low. It is uncertain whether ARB (losartan 50 mg) compared to placebo (1 study, 226 participants) reduces: death (any-cause) (no events), adverse events (RR 19.34, 95% CI 1.14 to 328.30), eGFR rate of decline (MD 5.00 mL/min/1.73 m2, 95% CI 3.03 to 6.97), presence of proteinuria (MD -0.65 g/24 hours, 95% CI -0.78 to -0.52), systolic blood pressure (MD -0.80 mm Hg, 95% CI -3.89 to 2.29), or diastolic blood pressure (MD -1.10 mm Hg, 95% CI -3.29 to 1.09) because the certainty of the evidence is very low. It is uncertain whether ACEi (enalapril 20 mg, perindopril 2 mg or trandolapril 1 mg) compared to ARB (olmesartan 20 mg, losartan 25 mg or candesartan 4 mg) (1 study, 26 participants) reduces: proteinuria (MD -0.40, 95% CI -0.60 to -0.20), systolic blood pressure (MD -3.00 mm Hg, 95% CI -6.08 to 0.08) or diastolic blood pressure (MD -1.00 mm Hg, 95% CI -3.31 to 1.31) because the certainty of the evidence is very low. AUTHORS' CONCLUSIONS There is currently insufficient evidence to determine the effectiveness of ACEi or ARB in patients with stage 1 to 3 CKD who do not have DM. The available evidence is overall of very low certainty and high risk of bias. We have identified an area of large uncertainty for a group of patients who account for most of those diagnosed as having CKD.
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Affiliation(s)
- Tess E Cooper
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Claris Teng
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | | | - Brydee A Cashmore
- Centre for Kidney Research, The University of Sydney and The Children's Hospital at Westmead, Sydney, Australia
| | - Giovanni Fm Strippoli
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Palhares Aversa Santos G, Inomata Cardoso da Silva D, Burgugi Banin V, Garcia Zanati Bazan S, Barretti P, Jorge da Silva Franco R, Martin LC. Reduction of proteinuria in patients with diabetes kidney disease and dysautonomia through measures aimed at controlling supine hypertension. Chronobiol Int 2022; 39:1220-1225. [PMID: 35786235 DOI: 10.1080/07420528.2022.2088377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
In diabetes kidney disease (DKD), orthostatic hypotension and supine hypertension often coexist, which, when uncontrolled, contributes to the progression of proteinuria and renal dysfunction. Chronotherapy and elevation of the head of the bed during sleep are feasible clinical measures and could contribute to the control of supine hypertension and proteinuria in this group of patients. This study consists of a series of cases, in which nine consecutive patients with DKD, dysautonomia and supine hypertension (intervention group) were instructed to use chronotherapy and inclination of the head of the bed in six degrees during sleep. These patients were compared with a historical control group. The primary outcome was proteinuria behavior. The intervention group had a significant drop in proteinuria levels, while there was an increase in proteinuria in the control group (variation in the proteinuria/creatininuria index in an isolated sample from the intervention group: -6.60 ± 3.90 g/g; variation in the group control: +1.70 ± 7.10 g/g, p = 0.008). Chronotherapy and six-degree inclination of the head of the bed during sleep were associated with a significant decrease in proteinuria in patients in the intervention group, with conversion of nephrotic into non-nephrotic proteinuria in most of these patients.
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Affiliation(s)
| | | | - Vanessa Burgugi Banin
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (Unesp), Botucatu, Brazil
| | - Silméia Garcia Zanati Bazan
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (Unesp), Botucatu, Brazil
| | - Pasqual Barretti
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (Unesp), Botucatu, Brazil
| | | | - Luis Cuadrado Martin
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (Unesp), Botucatu, Brazil
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Mallik R, Chowdhury TA. Pharmacotherapy to delay the progression of diabetic kidney disease in people with type 2 diabetes: past, present and future. Ther Adv Endocrinol Metab 2022; 13:20420188221081601. [PMID: 35281302 PMCID: PMC8905210 DOI: 10.1177/20420188221081601] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 01/28/2022] [Indexed: 12/14/2022] Open
Abstract
Diabetic kidney disease (DKD) is a leading cause of morbidity and mortality among people living with diabetes, and is one of the most important causes of end stage renal disease worldwide. In order to reduce progression of DKD, important management goals include treatment of hypertension, glycaemia and control of cardiovascular risk factors such as lipids, diet, smoking and exercise. Use of angiotensin converting enzyme inhibitors or angiotensin receptor blockers has an established role in prevention of progression of DKD. A number of other agents such as endothelin-1 receptor antagonists and bardoxolone have had disappointing results. Recent studies have, however, suggested that newer antidiabetic agents such as sodium-glucose transporter-2 inhibitors (SGLT-2i) and glucagon-like peptide-1 analogues have specific beneficial effects in patients with DKD. Indeed most recent guidance suggest that SGLT-2i drugs should be used early in DKD, irrespective of glucose control. A number of pathways are hypothesised for the development and progression of DKD, and have opened up a number of newer potential therapeutic targets. This article aims to discuss management of DKD with respect to seminal trials from the past, more recent trials informing the present and potential new therapeutic options that may be available in the future.
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Affiliation(s)
- Ritwika Mallik
- Department of Diabetes and Metabolism, The Royal London Hospital, London, UK
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6
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Akazawa S, Sadashima E, Sera Y, Koga N. Decline in the estimated glomerular filtration rate (eGFR) following metabolic control and its relationship with baseline eGFR in type 2 diabetes with microalbuminuria or macroalbuminuria. Diabetol Int 2021; 13:148-159. [DOI: 10.1007/s13340-021-00517-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/02/2021] [Indexed: 10/20/2022]
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7
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Hakroush S, Tampe D, Korsten P, Tampe B. Impact of the COVID-19 Pandemic on Kidney Diseases Requiring Renal Biopsy: A Single Center Observational Study. Front Physiol 2021; 12:649336. [PMID: 34305628 PMCID: PMC8297651 DOI: 10.3389/fphys.2021.649336] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/18/2021] [Indexed: 12/23/2022] Open
Abstract
Background The coronavirus disease-2019 (COVID-19) pandemic impacted healthcare services for kidney disease patients. Lockdown and social distancing were mandated worldwide, resulting in closure of medical services. The diagnosis of various kidney diseases may have been delayed during the COVID-19 pandemic because non-urgent tests and visits were postponed due to closure of medical services during the lockdown. Methods We here report the impact of the COVID-19 pandemic on a total number of 209 native kidney diseases requiring renal biopsy for diagnosis in a retrospective observational study from a tertiary hospital in Germany. Results The lockdown period in March and April 2020 primarily affected patients admitted to the normal medical ward with a compensatory increased rate of renal biopsies in the postlockdown phase. In addition, there was a shift toward more patients admitted with hemoglobinuria during the COVID-19 pandemic. This phenomenon of an increased number of patients with hemoglobinuria during the COVID-19 pandemic was specifically observed in a subgroup with hypertensive nephropathy requiring renal biopsy and associated with increased proteinuria, not attributed to the COVID-19 lockdown period itself. Conclusion To our knowledge, this is the first report of identifying a subpopulation susceptible to closure of medical services during the COVID-19 pandemic and diagnostic delay of specific kidney diseases. Therefore, the COVID-19 pandemic should be regarded as a risk factor especially in patients with diseases other than COVID-19 primarily admitted to the normal medical ward.
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Affiliation(s)
- Samy Hakroush
- Institute of Pathology, University Medical Center Göttingen, Göttingen, Germany
| | - Désirée Tampe
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
| | - Peter Korsten
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
| | - Björn Tampe
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
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Bensaada I, Robin B, Perez J, Salemkour Y, Chipont A, Camus M, Lemoine M, Guyonnet L, Lazareth H, Letavernier E, Hénique C, Tharaux PL, Lenoir O. Calpastatin prevents Angiotensin II-mediated podocyte injury through maintenance of autophagy. Kidney Int 2021; 100:90-106. [PMID: 33675847 DOI: 10.1016/j.kint.2021.02.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 01/29/2021] [Accepted: 02/10/2021] [Indexed: 12/20/2022]
Abstract
The strong predictive value of proteinuria in chronic glomerulopathies is firmly established as well as the pathogenic role of angiotensin II promoting progression of glomerular disease with an altered glomerular filtration barrier, podocyte injury and scarring of glomeruli. Here we found that chronic angiotensin II-induced hypertension inhibited autophagy flux in mouse glomeruli. Deletion of Atg5 (a gene encoding a protein involved autophagy) specifically in the podocyte resulted in accelerated angiotensin II-induced podocytopathy, accentuated albuminuria and glomerulosclerosis. This indicates that autophagy is a key protective mechanism in the podocyte in this condition. Angiotensin-II induced calpain activity in podocytes inhibits autophagy flux. Podocytes from mice with transgenic expression of the endogenous calpain inhibitor calpastatin displayed higher podocyte autophagy at baseline that was resistant to angiotensin II-dependent inhibition. Also, sustained autophagy with calpastatin limited podocyte damage and albuminuria. These findings suggest that hypertension has pathogenic effects on the glomerular structure and function, in part through activation of calpains leading to blockade of podocyte autophagy. These findings uncover an original mechanism whereby angiotensin II-mediated hypertension inhibits autophagy via calcium-induced recruitment of calpain with pathogenic consequences in case of imbalance by calpastatin activity. Thus, preventing a calpain-mediated decrease in autophagy may be a promising new therapeutic strategy for nephropathies associated with high renin-angiotensin system activity.
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Affiliation(s)
| | - Blaise Robin
- Université de Paris, PARCC, Inserm, Paris, France
| | - Joëlle Perez
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | | | - Anna Chipont
- Université de Paris, PARCC, Inserm, Paris, France
| | - Marine Camus
- Université de Paris, PARCC, Inserm, Paris, France
| | | | - Lea Guyonnet
- Université de Paris, PARCC, Inserm, Paris, France
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9
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Atkinson MA, Ng DK, Warady BA, Furth SL, Flynn JT. The CKiD study: overview and summary of findings related to kidney disease progression. Pediatr Nephrol 2021; 36:527-538. [PMID: 32016626 PMCID: PMC7396280 DOI: 10.1007/s00467-019-04458-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 12/10/2019] [Accepted: 12/16/2019] [Indexed: 12/15/2022]
Abstract
The Chronic Kidney Disease in Children (CKiD) cohort study is a North American (USA and Canada) multicenter, prospective study of children with chronic kidney disease (CKD). The original aims of the study were (1) to identify novel risk factors for CKD progression; (2) to measure the impact of kidney function decline on growth, cognition, and behavior; and (3) to characterize the evolution of cardiovascular disease risk factors. CKiD has developed into a national and international resource for the investigation of a variety of factors related to CKD in children. This review highlights notable findings in the area of CKD progression and outlines ongoing opportunities to enhance understanding of CKD progression in children. CKiD's contributions to the clinical care of children with CKD include updated and more accurate glomerular filtration rate estimating equations for children and young adults, and resources designed to help estimate the CKD progression timeline. In addition, results from CKiD have strengthened the evidence that treatment of hypertension and proteinuria should continue as a primary strategy for slowing the rate of disease progression in children.
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Affiliation(s)
| | - Derek K. Ng
- Johns Hopkins Bloomberg School of Public Health
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10
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McLeod DJ, Ching CB, Sebastião YV, Greenberg JH, Furth SL, McHugh KM, Becknell B. Common clinical markers predict end-stage renal disease in children with obstructive uropathy. Pediatr Nephrol 2019; 34:443-448. [PMID: 30317433 PMCID: PMC6500428 DOI: 10.1007/s00467-018-4107-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 09/12/2018] [Accepted: 09/28/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Obstructive uropathy (OU) is a common cause of end-stage renal disease (ESRD) in children. Children who escape the newborn period with mild-to-moderate chronic kidney disease (CKD) continue to be at increased risk. The predictive ability of clinically available markers throughout childhood is poorly defined. METHODS Patients with OU were identified in the Chronic Kidney Disease in Children Study. The primary outcome of interest was renal replacement therapy (RRT) (cases). Controls were age matched and defined as patients within the OU cohort who did not require RRT during study follow-up. RESULTS In total, 27 cases and 41 age-matched controls were identified. Median age at baseline and age at outcome measurement were 10 vs. 16 years, respectively. First available glomerular filtration rate (GFR) (36.9 vs. 53.5 mL/min per 1.73 m2), urine protein/creatinine (Cr) (0.40 vs. 0.22 mg/mg) and microalbumin/Cr (0.58 vs. 0.03 mg/mg), and serum CO2 (20 vs. 22 mmol/L) and hemoglobin (12.4 vs. 13.2 g/dL) differed significantly between cases and controls, respectively. GFR declined 3.07 mL/min per 1.73 m2/year faster in cases compared to that in controls (p < 0.0001). Urine protein/Cr and microalbumin/Cr increased by 0.16 and 0.11 per year more in cases compared to those in controls, respectively (p ≤ 0.001 for both). Serum phosphate increased by 0.11 mg/dL and serum albumin and hemoglobin decreased by 0.04 (g/dL) and 0.14 (g/dL) per year more for cases compared to those for controls, respectively (p < 0.05 for all). CONCLUSIONS Age-specific baseline and longitudinal measures of readily available clinical measures predict progression to ESRD in children with mild-to-moderate CKD from OU.
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Affiliation(s)
- Daryl J. McLeod
- Section of Urology, Nationwide Children’s Hospital, Columbus, OH 43205, USA,Center for Surgical Outcomes Research, Nationwide Children’s Hospital, Columbus, OH 43205, USA
| | - Christina B. Ching
- Section of Urology, Nationwide Children’s Hospital, Columbus, OH 43205, USA,Center for Clinical and Translational Research, Nationwide Children’s Hospital, Columbus, OH 43205, USA
| | - Yuri V. Sebastião
- Center for Surgical Outcomes Research, Nationwide Children’s Hospital, Columbus, OH 43205, USA
| | - Jason H. Greenberg
- Department of Pediatrics, Section of Nephrology, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Susan L. Furth
- Department of Pediatrics, Division of Nephrology, Perelman School of Medicine at the University of Pennsylvania and the Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Kirk M. McHugh
- Center for Clinical and Translational Research, Nationwide Children’s Hospital, Columbus, OH 43205, USA,Department of Biomedical Education & Anatomy, Ohio State University College of Medicine, Columbus, OH 43210, USA
| | - Brian Becknell
- Center for Clinical and Translational Research, Nationwide Children’s Hospital, Columbus, OH 43205, USA,Department of Pediatrics, Section of Nephrology, Nationwide Children’s Hospital, Columbus, OH 43205, USA
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11
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Sofue T, Suzuki H, Ueda N, Kushida Y, Minamino T. Post-transplant immunoglobulin A deposition and nephropathy in allografts. Nephrology (Carlton) 2018; 23 Suppl 2:4-9. [PMID: 29968406 DOI: 10.1111/nep.13281] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2018] [Indexed: 12/16/2022]
Abstract
Post-transplant immunoglobulin A (IgA) nephropathy (IgAN) in the allograft is the major cause of allograft loss. Using a protocol biopsy, latent mesangial IgA deposition (IgAD) can be detected in the allograft. Latent IgAD is distinguished from IgAN by the absence of urinary abnormalities, although IgA is observed in the mesangium. However, the pathophysiology and most appropriate treatment strategy for latent mesangial IgAD in the allograft remain to be fully determined. Importantly, it is unknown whether all cases of post-transplant asymptomatic IgAD progress to symptomatic IgAN; indeed, IgA deposits disappear in some cases. The differences in allograft prognosis between asymptomatic IgAD and IgAN have also not been determined. Non-invasive methods of diagnosis of IgAD in the allograft using serological and pathological biomarkers are being developed. Possible serum biomarkers include serum galactose-deficient IgA1 (Gd-IgA1), Gd-IgA1-specific IgG and Gd-IgA1-specific IgA, and its immune complexes. Immunofluorescence analysis using Gd-IgA1 monoclonal antibody may provide a pathological biomarker. These serological and pathological biomarkers may be suitable for the characterization of the stage of IgAD. However, there is insufficient information regarding whether serological and pathological biomarkers can predict the progression of asymptomatic IgAD to symptomatic IgAN. We propose that the pathogenesis of IgAN can be defined through the clinical study of IgAD in the allograft using protocol biopsies conducted by nephrologists involved in clinical kidney transplantation.
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Affiliation(s)
- Tadashi Sofue
- Division of Nephrology and Dialysis, Department of Cardiorenal and Cerebrovascular Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Hitoshi Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Nobufumi Ueda
- Department of Urology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Yoshio Kushida
- Department of Diagnostic Pathology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tetsuo Minamino
- Division of Nephrology and Dialysis, Department of Cardiorenal and Cerebrovascular Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
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12
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Subasi E, Subasi MM, Hammer PL, Roboz J, Anbalagan V, Lipkowitz MS. A Classification Model to Predict the Rate of Decline of Kidney Function. Front Med (Lausanne) 2017; 4:97. [PMID: 28770199 PMCID: PMC5516355 DOI: 10.3389/fmed.2017.00097] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 06/20/2017] [Indexed: 01/13/2023] Open
Abstract
The African American Study of Kidney Disease and Hypertension (AASK), a randomized double-blinded treatment trial, was motivated by the high rate of hypertension-related renal disease in the African-American population and the scarcity of effective therapies. This study describes a pattern-based classification approach to predict the rate of decline of kidney function using surface-enhanced laser desorption ionization/time of flight proteomic data from rapid and slow progressors classified by rate of change in glomerular filtration rate. An accurate classification model consisting of 7 out of 5,751 serum proteomic features is constructed by applying the logical analysis of data (LAD) methodology. On cross-validation by 10-folding, the model was shown to have an accuracy of 80.6 ± 0.11%, sensitivity of 78.4 ± 0.17%, and specificity of 78.5 ± 0.16%. The LAD discriminant is used to identify the patients in different risk groups. The LAD risk scores assigned to 116 AASK patients generated a receiver operating curves curve with AUC 0.899 (CI 0.845–0.953) and outperforms the risk scores assigned by proteinuria, one of the best predictors of chronic kidney disease progression.
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Affiliation(s)
- Ersoy Subasi
- Department of Engineering Systems, Florida Institute of Technology, Melbourne, FL, United States
| | - Munevver Mine Subasi
- Department of Mathematical Sciences, Florida Institute of Technology, Melbourne, FL, United States
| | - Peter L Hammer
- Rutgers Center for Operation Research, Rutgers University, Piscataway, NJ, United States
| | - John Roboz
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | - Michael S Lipkowitz
- Department of Medicine, Georgetown University Medical Center, Washington, DC, United States
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13
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Abraham AG, Betoko A, Fadrowski JJ, Pierce C, Furth SL, Warady BA, Muñoz A. Renin-angiotensin II-aldosterone system blockers and time to renal replacement therapy in children with CKD. Pediatr Nephrol 2017; 32:643-649. [PMID: 27826732 PMCID: PMC5336532 DOI: 10.1007/s00467-016-3512-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 08/25/2016] [Accepted: 08/30/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinical care decisions to treat chronic kidney disease (CKD) in a growing child must often be made without the benefit of evidence from clinical trials. We used observational data from the Chronic Kidney Disease in Children cohort to estimate the effectiveness of renin-angiotensin II-aldosterone system blockade (RAAS) to delay renal replacement therapy (RRT) in children with CKD. METHODS A total of 851 participants (median age: 11 years, median glomerular filtration rate [GFR]: 52 ml/min/1.73 m2, median urine protein to creatinine ratio: 0.35 mg/mg) were included. RAAS use was reported at annual study visits. Both Cox proportional hazards models with time-varying RAAS exposure and Cox marginal structural models (MSM) were used to evaluate the effect of RAAS use on time to RRT. Analyses were adjusted or weighted to control for age, male sex, glomerular diagnosis, GFR, nephrotic range proteinuria, anemia, elevated blood pressure, acidosis, elevated phosphate and elevated potassium. RESULTS There were 217 RRT events over a 4.1-year median follow-up. At baseline, 472 children (55 %) were prevalent RAAS users, who were more likely to be older, have a glomerular etiology, have higher urine protein, be anemic, have elevated serum phosphate and potassium, take more medications, but less likely to have elevated blood pressure, compared with non-users. RAAS use was found to reduce the risk of RRT by 21 % (hazard ratio: 0.79) to 37 % (hazard ratio: 0.63) from standard regression adjustment and MSM models, respectively. CONCLUSIONS These results support inferences from adult studies of a substantial benefit of RAAS use in pediatric CKD patients.
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Affiliation(s)
- Alison G Abraham
- Johns Hopkins School of Medicine, 600 N Wolfe Street, Baltimore, MD, 21287, United States.
- Johns Hopkins Bloomberg School of P, 615 N Wolfe Street, Baltimore, 21205, MD, United States.
| | - Aisha Betoko
- Johns Hopkins Bloomberg School of P, 615 N Wolfe Street, Baltimore, 21205, MD, United States
| | - Jeffrey J Fadrowski
- Johns Hopkins School of Medicine, 600 N Wolfe Street, Baltimore, MD, 21287, United States
| | - Christopher Pierce
- Johns Hopkins Bloomberg School of P, 615 N Wolfe Street, Baltimore, 21205, MD, United States
| | - Susan L Furth
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Alvaro Muñoz
- Johns Hopkins Bloomberg School of P, 615 N Wolfe Street, Baltimore, 21205, MD, United States
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14
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Xue C, Zhou C, Dai B, Yu S, Xu C, Mao Z, Ye C, Chen D, Zhao X, Wu J, Chen W, Mei C. Antihypertensive treatments in adult autosomal dominant polycystic kidney disease: network meta-analysis of the randomized controlled trials. Oncotarget 2016; 6:42515-29. [PMID: 26636542 PMCID: PMC4767449 DOI: 10.18632/oncotarget.6452] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 11/21/2015] [Indexed: 11/25/2022] Open
Abstract
Background Blood pressure (BP) control is one of the most important treatments of Autosomal dominant polycystic kidney disease (ADPKD). The comparative efficacy of antihypertensive treatments in ADPKD patients is inconclusive. Methods Network meta-analysis was used to evaluate randomized controlled trials (RCT) which investigated antihypertensive treatments in ADPKD. PubMed, Embase, Ovid, and Cochrane Collaboration were searched. The primary outcome was estimated glomerular filtration rate (eGFR). Secondary outcomes were serum creatinine (Scr), urinary albumin excretion (UAE), systolic BP (SBP), diastolic BP (DBP), mean artery pressure (MAP) and left ventricular mass index (LVMI). Results We included 10 RCTs with 1386 patients and six interventions: angiotensin-converting enzyme inhibitors (ACEI), Angiotensin II receptor blocker (ARB), combination of ACEI and ARB, calcium channel blockers (CCB), β-blockers and dilazep. There was no difference of eGFR in all the treatments in both network and direct comparisons. No significant differences of Scr, SBP, DBP, MAP, and LVMI were found in network comparisons. However, ACEI significantly reduced SBP, DBP, MAP and LVMI when compared to CCB. Significantly increased UAE was observed in CCB compared with ACEI or ARB. Bayesian probability analysis found ARB ranked first in the surrogate measures of eGFR, UAE and SBP. Conclusions There is little evidence to detect differences of antihypertensive treatments on kidney disease progression in ADPKD patients. More RCTs will be needed in the future. Use of ARB may be an optimal choice in clinical practice.
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Affiliation(s)
- Cheng Xue
- Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China.,Department of Nephrology, PLA 309 Hospital, Beijing, China
| | - Chenchen Zhou
- Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Bing Dai
- Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Shengqiang Yu
- Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Chenggang Xu
- Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Zhiguo Mao
- Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Chaoyang Ye
- Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Dongping Chen
- Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Xuezhi Zhao
- Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Jun Wu
- Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Wansheng Chen
- Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China.,Department of Pharmacy, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Changlin Mei
- Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
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15
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Al-Balas A, Lee T, Young CJ, Barker-Finkel J, Allon M. Predictors of Initiation for Predialysis Arteriovenous Fistula. Clin J Am Soc Nephrol 2016; 11:1802-1808. [PMID: 27630181 PMCID: PMC5053781 DOI: 10.2215/cjn.00700116] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 06/06/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The optimal timing of predialysis arteriovenous fistula surgery remains uncertain. We evaluated factors associated with hemodialysis initiation in patients undergoing predialysis arteriovenous fistula surgery and derived a model to predict future initiation of dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Our study retrospectively identified 308 patients undergoing predialysis arteriovenous fistula creation at a large medical center in 2006-2012 to determine whether they initiated hemodialysis. Multiple variable logistic regression analyzed which demographic and clinical factors predicted initiation of dialysis within 2 years of arteriovenous fistula surgery. A receiver operating characteristic area under the curve was used to quantify the predictive value of preoperative factors on the likelihood of initiating hemodialysis within 2 years. RESULTS Overall, hemodialysis was initiated within 6 months, 1 year, and 2 years in 119 (39%), 175 (57%), and 211 (68%) patients, respectively. Using multiple variable logistic regression, four factors were associated with hemodialysis initiation at 2 years: eGFR at access surgery (odds ratio, 0.45; 95% confidence interval, 0.31 to 0.64 per 5 ml/min per 1.73 m2; P<0.001), diabetes (odds ratio, 2.51; 95% confidence interval, 1.22 to 5.15; P=0.003), GFR trajectory (odds ratio, 1.54; 95% confidence interval, 1.09 to 2.17 per 3 ml/min per 1.73 m2 per year; P=0.01), and spot urine protein-to-creatinine ratio (odds ratio, 1.39; 95% confidence interval, 1.14 to 1.71 per 1 U; P<0.001). eGFR alone had a moderate predictive value for dialysis initiation (area under the curve =0.69; 95% confidence interval, 0.63 to 0.76; P<0.001), whereas the full model had a higher predictive value (area under the curve =0.83; 95% confidence interval, 0.77 to 0.88; P<0.001). CONCLUSIONS The likelihood of initiating hemodialysis within 2 years of predialysis arteriovenous fistula surgery is associated with eGFR at access surgery, diabetes, GFR trajectory, and magnitude of proteinuria. The combined use of all four variables improves the ability to predict future hemodialysis compared with the use of eGFR alone.
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Affiliation(s)
| | - Timmy Lee
- Department of Medicine and Division of Nephrology and
- Division of Nephrology, Veterans Affairs Medical Center, Birmingham, Alabama; and
| | - Carlton J. Young
- Department of Surgery and Division of Transplantation, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Michael Allon
- Department of Medicine and Division of Nephrology and
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16
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Ruggenenti P, Gentile G, Perico N, Perna A, Barcella L, Trillini M, Cortinovis M, Ferrer Siles CP, Reyes Loaeza JA, Aparicio MC, Fasolini G, Gaspari F, Martinetti D, Carrara F, Rubis N, Prandini S, Caroli A, Sharma K, Antiga L, Remuzzi A, Remuzzi G. Effect of Sirolimus on Disease Progression in Patients with Autosomal Dominant Polycystic Kidney Disease and CKD Stages 3b-4. Clin J Am Soc Nephrol 2016; 11:785-794. [PMID: 26912555 PMCID: PMC4858487 DOI: 10.2215/cjn.09900915] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 01/26/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES The effect of mammalian target of rapamycin (mTOR) inhibitors has never been tested in patients with autosomal dominant polycystic kidney disease (ADPKD) and severe renal insufficiency. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this academic, prospective, randomized, open label, blinded end point, parallel group trial (ClinicalTrials.gov no. NCT01223755), 41 adults with ADPKD, CKD stage 3b or 4, and proteinuria ≤0.5 g/24 h were randomized between September of 2010 and March of 2012 to sirolimus (3 mg/d; serum target levels of 5-10 ng/ml) added on to conventional therapy (n=21) or conventional treatment alone (n=20). Primary outcome was GFR (iohexol plasma clearance) change at 1 and 3 years versus baseline. RESULTS At the 1-year preplanned interim analysis, GFR fell from 26.7±5.8 to 21.3±6.3 ml/min per 1.73 m(2) (P<0.001) and from 29.6±5.6 to 24.9±6.2 ml/min per 1.73 m(2) (P<0.001) in the sirolimus and conventional treatment groups, respectively. Albuminuria (73.8±81.8 versus 154.9±152.9 μg/min; P=0.02) and proteinuria (0.3±0.2 versus 06±0.4 g/24 h; P<0.01) increased with sirolimus. Seven patients on sirolimus versus one control had de novo proteinuria (P=0.04), ten versus three patients doubled proteinuria (P=0.02), 18 versus 11 patients had peripheral edema (P=0.04), and 14 versus six patients had upper respiratory tract infections (P=0.03). Three patients on sirolimus had angioedema, 14 patients had aphthous stomatitis, and seven patients had acne (P<0.01 for both versus controls). Two patients progressed to ESRD, and two patients withdrew because of worsening of proteinuria. These events were not observed in controls. Thus, the independent data and safety monitoring board recommend early trial termination for safety reasons. At 1 year, total kidney volume (assessed by contrast-enhanced computed tomography imaging) increased by 9.0% from 2857.7±1447.3 to 3094.6±1519.5 ml on sirolimus and 4.3% from 3123.4±1695.3 to 3222.6±1651.4 ml on conventional therapy (P=0.12). On follow-up, 37% and 7% of serum sirolimus levels fell below or exceeded the therapeutic range, respectively. CONCLUSIONS Finding that sirolimus was unsafe and ineffective in patients with ADPKD and renal insufficiency suggests that mTOR inhibitor therapy may be contraindicated in this context.
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Affiliation(s)
- Piero Ruggenenti
- Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
- Units of Nephrology and Dialysis
| | - Giorgio Gentile
- Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
- Units of Nephrology and Dialysis
| | - Norberto Perico
- Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Annalisa Perna
- Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | | | - Matias Trillini
- Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Monica Cortinovis
- Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Claudia Patricia Ferrer Siles
- Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Jorge Arturo Reyes Loaeza
- Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Maria Carolina Aparicio
- Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Giorgio Fasolini
- Radiology, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy; and
| | - Flavio Gaspari
- Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Davide Martinetti
- Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Fabiola Carrara
- Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Nadia Rubis
- Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Silvia Prandini
- Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Anna Caroli
- Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Kanishka Sharma
- Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Luca Antiga
- Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Andrea Remuzzi
- Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
| | - Giuseppe Remuzzi
- Clinical Research Center for Rare Diseases “Aldo e Cele Daccò,” IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri,” Bergamo, Italy
- Units of Nephrology and Dialysis
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
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17
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Abstract
Globally, IgA nephropathy (IgAN) is the most common primary glomerulonephritis that can progress to renal failure. The exact pathogenesis of IgAN is not well defined, but current biochemical and genetic data implicate overproduction of aberrantly glycosylated IgA1. These aberrant immunoglobulins are characterized by galactose deficiency of some hinge-region O-linked glycans. However, aberrant glycosylation alone is insufficient to induce renal injury: the participation of glycan-specific IgA and IgG autoantibodies that recognize the undergalactosylated IgA1 molecule is required. Glomerular deposits of immune complexes containing undergalactosylated IgA1 activate mesangial cells, leading to the local overproduction of cytokines, chemokines and complement. Emerging data indicate that mesangial-derived mediators that are released following mesangial deposition of IgA1 lead to podocyte and tubulointerstitial injury via humoral crosstalk. Patients can present with a range of signs and symptoms, from asymptomatic microscopic haematuria to macroscopic haematuria. The clinical progression varies, with 30-40% of patients reaching end-stage renal disease 20-30 years after the first clinical presentation. Currently, no IgAN-specific therapies are available and patients are managed with the aim of controlling blood pressure and maintaining renal function. However, new therapeutic approaches are being developed, building upon our ever-improving understanding of disease pathogenesis.
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18
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Barbour SJ, Espino-Hernandez G, Reich HN, Coppo R, Roberts IS, Feehally J, Herzenberg AM, Cattran DC, Bavbek N, Cook T, Troyanov S, Alpers C, Amore A, Barratt J, Berthoux F, Bonsib S, Bruijn J, D’Agati V, D’Amico G, Emancipator S, Emmal F, Ferrario F, Fervenza F, Florquin S, Fogo A, Geddes C, Groene H, Haas M, Hill P, Hogg R, Hsu S, Hunley T, Hladunewich M, Jennette C, Joh K, Julian B, Kawamura T, Lai F, Leung C, Li L, Li P, Liu Z, Massat A, Mackinnon B, Mezzano S, Schena F, Tomino Y, Walker P, Wang H, Weening J, Yoshikawa N, Zhang H, Coppo R, Troyanov S, Cattran D, Cook H, Feehally J, Roberts I, Tesar V, Maixnerova D, Lundberg S, Gesualdo L, Emma F, Fuiano L, Beltrame G, Rollino C, RC, Amore A, Camilla R, Peruzzi L, Praga M, Feriozzi S, Polci R, Segoloni G, Colla L, Pani A, Angioi A, Piras L, JF, Cancarini G, Ravera S, Durlik M, Moggia E, Ballarin J, Di Giulio S, Pugliese F, Serriello I, Caliskan Y, Sever M, Kilicaslan I, Locatelli F, Del Vecchio L, Wetzels J, Peters H, Berg U, Carvalho F, da Costa Ferreira A, Maggio M, Wiecek A, Ots-Rosenberg M, Magistroni R, Topaloglu R, Bilginer Y, D’Amico M, Stangou M, Giacchino F, Goumenos D, Kalliakmani P, Gerolymos M, Galesic K, Geddes C, Siamopoulos K, Balafa O, Galliani M, Stratta P, Quaglia M, Bergia R, Cravero R, Salvadori M, Cirami L, Fellstrom B, Kloster Smerud H, Ferrario F, Stellato T, Egido J, Martin C, Floege J, Eitner F, Lupo A, Bernich P, Menè P, Morosetti M, van Kooten C, Rabelink T, Reinders M, Boria Grinyo J, Cusinato S, Benozzi L, Savoldi S, Licata C, Mizerska-Wasiak M, Martina G, Messuerotti A, Dal Canton A, Esposito C, Migotto C, Triolo G, Mariano F, Pozzi C, Boero R, Bellur S, Mazzucco G, Giannakakis C, Honsova E, Sundelin B, Di Palma A, Ferrario F, Gutiérrez E, Asunis A, Barratt J, Tardanico R, Perkowska-Ptasinska A, Arce Terroba J, Fortunato M, Pantzaki A, Ozluk Y, Steenbergen E, Soderberg M, Riispere Z, Furci L, Orhan D, Kipgen D, Casartelli D, Galesic Ljubanovic D, Gakiopoulou H, Bertoni E, Cannata Ortiz P, Karkoszka H, Groene H, Stoppacciaro A, Bajema I, Bruijn J, Fulladosa Oliveras X, Maldyk J, Ioachim E. The MEST score provides earlier risk prediction in lgA nephropathy. Kidney Int 2016; 89:167-75. [DOI: 10.1038/ki.2015.322] [Citation(s) in RCA: 150] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 08/17/2015] [Accepted: 09/03/2015] [Indexed: 01/12/2023]
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Montero RM, Covic A, Gnudi L, Goldsmith D. Diabetic nephropathy: What does the future hold? Int Urol Nephrol 2015; 48:99-113. [PMID: 26438328 PMCID: PMC4705119 DOI: 10.1007/s11255-015-1121-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 09/19/2015] [Indexed: 12/24/2022]
Abstract
The consensus management of diabetic nephropathy (DN) in 2015 involves good control of glycaemia, dyslipidaemia and blood pressure (BP). Blockade of the renin-angiotensin-aldosterone system using angiotensin-converting enzyme inhibitors, angiotensin-2 receptor blockers or mineralocorticoid inhibitors are key therapeutic approaches, shown to be beneficial once overt nephropathy is manifest, as either, or both, of albuminuria and loss of glomerular filtration rate. Some significant additional clinical benefits in slowing the progression of DN was reported from the Remission clinic experience, where simultaneous intensive control of BP, tight glycaemic control, weight loss, exercise and smoking cessation were prioritised in the management of DN. This has not proved possible to translate to more conventional clinical settings. This review briefly looks over the history and limitations of current therapy from landmark papers and expert reviews, and following an extensive PubMed search identifies the most promising clinical biomarkers (both established and proposed). Many challenges need to be addressed urgently as in order to obtain novel therapies in the clinic; we also need to examine what we mean by remission, stability and progression of DN in the modern era.
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Affiliation(s)
- R M Montero
- Renal, Dialysis and Transplantation Unit, Guy's and St Thomas' Hospital, London, UK.
| | - A Covic
- Hospital "C.I.Parhon" and University of Medicine "Grigore T Popa", Iasi, Romania
| | - L Gnudi
- Cardiovascular Division, Department of Diabetes and Endocrinology, Guy's and St Thomas' Hospital, School of Medicine and Life Science, King's College London, London, UK
| | - D Goldsmith
- Renal, Dialysis and Transplantation Unit, Guy's and St Thomas' Hospital, London, UK
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20
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Wasser WG, Gil A, Skorecki KL. The Envy of Scholars: Applying the Lessons of the Framingham Heart Study to the Prevention of Chronic Kidney Disease. Rambam Maimonides Med J 2015; 6:RMMJ.10214. [PMID: 26241225 PMCID: PMC4524402 DOI: 10.5041/rmmj.10214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
During the past 50 years, a dramatic reduction in the mortality rate associated with cardiovascular disease has occurred in the US and other countries. Statistical modeling has revealed that approximately half of this reduction is the result of risk factor mitigation. The successful identification of such risk factors was pioneered and has continued with the Framingham Heart Study, which began in 1949 as a project of the US National Heart Institute (now part of the National Heart, Lung, and Blood Institute). Decreases in total cholesterol, blood pressure, smoking, and physical inactivity account for 24%, 20%, 12%, and 5% reductions in the mortality rate, respectively. Nephrology was designated as a recognized medical professional specialty a few years later. Hemodialysis was first performed in 1943. The US Medicare End-Stage Renal Disease (ESRD) Program was established in 1972. The number of patients in the program increased from 5,000 in the first year to more than 500,000 in recent years. Only recently have efforts for risk factor identification, early diagnosis, and prevention of chronic kidney disease (CKD) been undertaken. By applying the approach of the Framingham Heart Study to address CKD risk factors, we hope to mirror the success of cardiology; we aim to prevent progression to ESRD and to avoid the cardiovascular complications associated with CKD. In this paper, we present conceptual examples of risk factor modification for CKD, in the setting of this historical framework.
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Affiliation(s)
- Walter G. Wasser
- Division of Nephrology, Mayanei HaYeshua Medical Center, Bnei Brak, Israel
- Division of Nephrology, Rambam Health Care Campus, Haifa, Israel
- To whom correspondence should be addressed. E-mail:
| | - Amnon Gil
- Division of Nephrology, Carmel Medical Center, Haifa, Israel
| | - Karl L. Skorecki
- Division of Nephrology, Rambam Health Care Campus, Haifa, Israel
- Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Director of Medical and Research Development, Rambam Health Care Campus, Haifa, Israel
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21
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De Nicola L, Provenzano M, Chiodini P, Borrelli S, Garofalo C, Pacilio M, Liberti ME, Sagliocca A, Conte G, Minutolo R. Independent Role of Underlying Kidney Disease on Renal Prognosis of Patients with Chronic Kidney Disease under Nephrology Care. PLoS One 2015; 10:e0127071. [PMID: 25992629 PMCID: PMC4439030 DOI: 10.1371/journal.pone.0127071] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 04/11/2015] [Indexed: 12/22/2022] Open
Abstract
Primary kidney disease is suggested to affect renal prognosis of CKD patients; however, whether nephrology care modifies this association is unknown. We studied patients with CKD stage I-IV treated in a renal clinic and with established diagnosis of CKD cause to evaluate whether the risk of renal event (composite of end-stage renal disease and eGFR decline ≥40%) linked to the specific diagnosis is modified by the achievement or maintenance in the first year of nephrology care of therapeutic goals for hypertension (BP ≤130/80 mmHg in patients with proteinuria ≥150 mg/24h and/or diabetes and ≤140/90 in those with proteinuria <150 mg/24h and without diabetes) anemia (hemoglobin, Hb ≥11 g/dL), and proteinuria (≤0.5 g/24h). Survival analysis started after first year of nephrology care. We studied 729 patients (age 64±15 y; males 59.1%; diabetes 34.7%; cardiovascular disease (CVD) 44.9%; hypertensive nephropathy, HTN 53.8%; glomerulonephritis, GN 17.3%; diabetic nephropathy, DN 15.9%; tubule-interstitial nephropathy, TIN 9.5%; polycystic kidney disease, PKD 3.6%). During first year of Nephrology care, therapy was overall intensified in most patients and prevalence of main therapeutic goals generally improved. During subsequent follow up (median 3.3 years, IQR 1.9-5.1), 163 renal events occurred. Cox analysis disclosed a higher risk for PKD (Hazard Ratio 5.46, 95% Confidence Intervals 2.28–10.6) and DN (1.28,2.99–3.05), versus HTN (reference), independently of age, gender, CVD, BMI, eGFR or CKD stage, use of RAS inhibitors and achievement or maintenance in the first year of nephrology care of each of the three main therapeutic goals. No interaction was found on the risk of CKD progression between diagnostic categories and month-12 eGFR (P=0.737), as with control of BP (P=0.374), Hb (P=0.248) or proteinuria (P=0.590). Therefore, in CKD patients under nephrology care, diagnosis of kidney disease should be considered in conjunction with the main risk factors to refine renal risk stratification.
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Affiliation(s)
- Luca De Nicola
- Nephrology Division School of Medicine-Second University of Naples, Naples, Italy
- * E-mail:
| | - Michele Provenzano
- Nephrology Division School of Medicine-Second University of Naples, Naples, Italy
| | - Paolo Chiodini
- Medical Statistics Unit School of Medicine-Second University of Naples, Naples, Italy
| | - Silvio Borrelli
- Nephrology Division School of Medicine-Second University of Naples, Naples, Italy
| | - Carlo Garofalo
- Nephrology Division School of Medicine-Second University of Naples, Naples, Italy
| | - Mario Pacilio
- Nephrology Division School of Medicine-Second University of Naples, Naples, Italy
| | - Maria Elena Liberti
- Nephrology Division School of Medicine-Second University of Naples, Naples, Italy
| | - Adelia Sagliocca
- Nephrology Division School of Medicine-Second University of Naples, Naples, Italy
| | - Giuseppe Conte
- Nephrology Division School of Medicine-Second University of Naples, Naples, Italy
| | - Roberto Minutolo
- Nephrology Division School of Medicine-Second University of Naples, Naples, Italy
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Porrini E, Ruggenenti P, Mogensen CE, Barlovic DP, Praga M, Cruzado JM, Hojs R, Abbate M, de Vries APJ. Non-proteinuric pathways in loss of renal function in patients with type 2 diabetes. Lancet Diabetes Endocrinol 2015; 3:382-91. [PMID: 25943757 DOI: 10.1016/s2213-8587(15)00094-7] [Citation(s) in RCA: 143] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 02/11/2015] [Accepted: 02/13/2015] [Indexed: 12/13/2022]
Abstract
Largely on the basis of data from patients with type 1 diabetes, the natural history of diabetic renal disease has been classified as a sequence of three stages: normoalbuminuria, microalbuminuria, and macroalbuminuria. Progressive decline of glomerular filtration rate (GFR) was thought to parallel the onset of macroalbuminuria (overt nephropathy), whereas glomerular hyperfiltration was deemed a hallmark of early disease. However, researchers have since shown that albuminuria is a continuum and that GFR can start to decline before progression to overt nephropathy. In addition to proteinuria, other risk factors might contribute to GFR deterioration including female sex, obesity, dyslipidaemia (in particular hypertriglyceridaemia), hypertension, and glomerular hyperfiltration, at least in a subgroup of patients. This phenomenon could explain why patients with type 2 diabetes can have renal insufficiency even before the onset of overt nephropathy, and might also suggest why the heterogeneous phenotype of type 2 diabetic renal disease does not necessarily associate with typical histological lesions of diabetic renal disease, unlike in type 1 diabetic renal disease. Patients with renal insufficiency but without albuminuria are usually excluded from randomised clinical trials in overt nephropathy, thus optimum treatment for this group of patients is unknown. The wide inter-patient variability of the disease probably needs individually tailored intervention.
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Affiliation(s)
- Esteban Porrini
- Center for Biomedical Research of the Canary Islands (CIBICAN), University of La Laguna, Tenerife, Spain.
| | - Piero Ruggenenti
- Mario Negri Institute for Pharmacological Research, Bergamo, Italy
| | | | - Drazenka Pongrac Barlovic
- Department of Endocrinology, Diabetes and Metabolism, Ljubljana University Medical Center, Ljubljana, Slovenia
| | - Manuel Praga
- Department of Nephrology, Hospital 12 de Octubre, Madrid, Spain
| | - Josep M Cruzado
- Department of Nephrology, Hospital Universitario de Bellvitge, Barcelona, Spain
| | - Radovan Hojs
- Department of Nephrology, Clinic for Internal Medicine, University Clinical Centre and Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Manuela Abbate
- Department of Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Aiko P J de Vries
- Division of Nephrology, Department of Medicine, Leiden University Medical Center and Leiden University, Leiden, Netherlands
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Complete inhibition of the renin-angiotensin-aldosterone system; where do we stand? Curr Opin Nephrol Hypertens 2015; 23:449-55. [PMID: 25014549 DOI: 10.1097/mnh.0000000000000043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE OF REVIEW This review presents the role of combination therapy of renin-angiotensin-aldosterone system blockade on cardiovascular and kidney disease. RECENT FINDINGS Three large randomized controlled trials comparing combination therapy of renin-angiotensin-aldosterone system blockade to monotherapy in individuals with increased cardiovascular risk, chronic kidney disease, or diabetic nephropathy have been reported. These trials - ONTARGET, ALTITUDE, and VA NEPHRON-D - demonstrated an excess risk of adverse effects [especially acute kidney injury (AKI) and hyperkalemia] with combination therapy, without significant benefit in reducing cardiovascular and renal morbidity. SUMMARY Current evidence supports avoiding dual renin-angiotensin-aldosterone system blockade in patients with chronic kidney disease. Subsequent studies of dual renin-angiotensin-aldosterone system blockade should examine adverse event risks and renal progression endpoints.
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24
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Blumenthal SS. Evolution of Treatment for Diabetic Nephropathy: Historical Progression from RAAS Inhibition and Onward. Postgrad Med 2015; 123:166-79. [DOI: 10.3810/pgm.2011.11.2506] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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25
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Kou J, Wu J, Yang HT, He YN, Fang JA, Deng YY, Xie YS, Nie LF, Lin HL, Cai GY, Chen XM. Efficacy and safety of Shenyankangfu tablets for primary glomerulonephritis: study protocol for a randomized controlled trial. Trials 2014; 15:479. [PMID: 25480673 PMCID: PMC4289030 DOI: 10.1186/1745-6215-15-479] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 11/17/2014] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Chronic kidney disease is a common disease. Most chronic kidney diseases evolve from primary glomerulonephritis. Proteinuria is an independent risk factor for the progression of chronic kidney disease. The general consensus is that therapy administered to decrease proteinuria should include steroids and/or immunosuppressants, angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers. However, the side effects of, and adverse reactions to, these agents reduce the benefits to patients. In addition, the cost of these drugs is relatively high. Therefore, identification of inexpensive and effective drugs to decrease proteinuria is urgently needed. Shenyankangfu tablets have been a widely applied Chinese patent medicine for many years to decrease proteinuria. However, there is a lack of research-derived data regarding the clinical use. Therefore, we designed the present randomized controlled clinical trial to compare the efficacy and safety of Shenyankangfu tablets versus losartan potassium for control of proteinuria in patients with primary glomerulonephritis. METHODS/DESIGN This study will be a multicenter, prospective, double-blind, double-dummy, randomized controlled clinical trial. We will enroll 720 patients diagnosed with primary glomerulonephritis. The eligible patients will be randomly divided into the following groups at a 1:1:1:1:1 ratio: Shenyankangfu tablets group, losartan potassium 50 mg group, losartan potassium 100 mg group, Shenyankangfu tablets + losartan potassium 50 mg group, and Shenyankangfu tablets + losartan potassium 100 mg group. All groups will be followed up for 48 weeks; follow-up visits will be performed, at weeks 0, 4, 8, 12, 24, 36, and 48. The primary efficacy outcome will be the post-treatment change in the 24-hour proteinuria level, and the secondary efficacy outcomes will be the post-treatment changes in the serum creatinine level, estimated glomerular filtration rate, traditional Chinese medicine syndrome score, and serum albumin level. DISCUSSION The results of this trial will provide solid data for use in evidence-based medicine with respect to the efficacy and safety of Shenyankangfu tablets for control of proteinuria in patients with primary glomerulonephritis compared to those of losartan potassium. Moreover, we infer that therapy comprising Shenyankangfu tablets + losartan potassium can decrease proteinuria to a larger extent than Shenyankangfu tablets or losartan potassium can alone. TRIAL REGISTRATION This trial was registered on 12 February 2014 at ClinicalTrials.gov (ID number NCT02063100).
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Affiliation(s)
- Jia Kou
- />Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center of Kidney Diseases, 28 Fuxing Road, Haidian District, Beijing, 100853 China
| | - Jie Wu
- />Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center of Kidney Diseases, 28 Fuxing Road, Haidian District, Beijing, 100853 China
| | - Hong-tao Yang
- />Department of Nephrology, The First Affiliated Hospital of Tianjin University of TCM, 314 West Anshan Road, Nankai District, Tianjin, 300193 China
| | - Ya-ni He
- />Department of Nephrology, Daping Hospital, The Third Military Medical University, 10 Changjiangzhilu Daping, Yuzhong District, Chongqing, 400042 China
| | - Jing-ai Fang
- />Department of Nephrology, First Hospital of Shanxi Medical University, 85 liberation Road, Taiyuan, Shanxi Province 030001 China
| | - Yue-yi Deng
- />Department of Nephrology, Longhua Hospital of Shanghai University of TCM, 725 South Wanping Road, Shanghai, 200032 China
| | - Yuan-sheng Xie
- />Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center of Kidney Diseases, 28 Fuxing Road, Haidian District, Beijing, 100853 China
| | - Li-fang Nie
- />Department of Nephrology, Xiyuan Hospital CACMS, 1 Xiyuan Playground, Haidian District, Beijing, 100091 China
| | - Hong-li Lin
- />Department of Nephrology, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, Zhongshan District, Dalian, Liaoning Province 116011 China
| | - Guang-yan Cai
- />Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center of Kidney Diseases, 28 Fuxing Road, Haidian District, Beijing, 100853 China
| | - Xiang-mei Chen
- />Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center of Kidney Diseases, 28 Fuxing Road, Haidian District, Beijing, 100853 China
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26
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Wang J, Liang M, Xu J, Cao W, Wang GB, Zhou ZM, Tian JW, Jia N, Zhang Z, Nie J, Liu Y, Hou FF. Renal expression of advanced oxidative protein products predicts progression of renal fibrosis in patients with IgA nephropathy. J Transl Med 2014; 94:966-77. [PMID: 25068662 DOI: 10.1038/labinvest.2014.90] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 04/24/2014] [Accepted: 05/29/2014] [Indexed: 12/19/2022] Open
Abstract
Predicting the risk of disease progression in IgA nephropathy (IgAN) remains a challenge. This study was conducted to test the hypothesis that renal accumulation of advanced oxidized protein products (AOPPs) is an early predictor for renal progression in IgAN. This was a single-center prospective cohort study. One hundred IgAN patients with eGFR>80 ml/min/1.73 m(2) were enrolled. Seventy-seven patients were followed for a mean of 4.2 years, and 30 patients received repeat renal biopsy at a mean of 42 months after diagnosis. The outcomes were the progression of renal fibrosis and rapid progression of CKD (>5 ml/min/1.73 m(2)/year) during follow-up. Immunoreactivity of AOPPs was detected predominantly in tubular epithelial cells and co-localized with expression of TGF-β1 and angiotensin II. Renal staining score of AOPPs at diagnosis was associated with the level of tissue cellular inflammation. Accumulation of AOPPs, particularly in interstitial-infiltrating cells, was negatively correlated with changes of eGFR during follow-up; those with expression scores greater than the median at diagnosis had significantly higher incidences of rapid decline of eGFR compared with those with the score less than or equal to the median. For patients who received repeat renal biopsy, renal AOPP levels greater than the median at diagnosis were associated with increase in renal fibrosis index at repeat biopsy. After multivariate adjustment, renal AOPP expression was an independent predictor for progression of renal fibrosis and rapid decline of eGFR. Taken together, these results demonstrate that renal AOPPs might be a predictor, detectable at the time of diagnosis, for renal progression in patients with early stage IgAN.
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Affiliation(s)
- Jun Wang
- National Clinical Research Center of Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Institute of Nephrology, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Min Liang
- National Clinical Research Center of Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Institute of Nephrology, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Jie Xu
- National Clinical Research Center of Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Institute of Nephrology, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Wei Cao
- National Clinical Research Center of Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Institute of Nephrology, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Guo B Wang
- National Clinical Research Center of Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Institute of Nephrology, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Zhan M Zhou
- National Clinical Research Center of Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Institute of Nephrology, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Jian W Tian
- National Clinical Research Center of Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Institute of Nephrology, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Nan Jia
- National Clinical Research Center of Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Institute of Nephrology, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Zhenhai Zhang
- National Clinical Research Center of Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Institute of Nephrology, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Jing Nie
- National Clinical Research Center of Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Institute of Nephrology, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Youhua Liu
- National Clinical Research Center of Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Institute of Nephrology, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
| | - Fan F Hou
- National Clinical Research Center of Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Institute of Nephrology, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
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Dhaun N, Webb DJ. Novel therapeutic approaches to chronic kidney disease. Br J Clin Pharmacol 2013; 76:491-4. [PMID: 24073602 PMCID: PMC3791972 DOI: 10.1111/bcp.12124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 01/23/2013] [Indexed: 11/28/2022] Open
Affiliation(s)
- Neeraj Dhaun
- Department of Renal Medicine, Royal Infirmary of Edinburgh, The Queen's Medical Research InstituteEdinburgh, UK
| | - David J Webb
- Clinical Pharmacology Unit, University of Edinburgh, The Queen's Medical Research InstituteEdinburgh, UK
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28
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Szeto CC, Kwan BCH, Chow KM, Leung CB, Li PKT. The safety and short-term efficacy of aliskiren in the treatment of immunoglobulin a nephropathy--a randomized cross-over study. PLoS One 2013; 8:e62736. [PMID: 23675422 PMCID: PMC3651209 DOI: 10.1371/journal.pone.0062736] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 03/25/2013] [Indexed: 12/16/2022] Open
Abstract
Background Laboratory research and previous study suggest that aliskiren, a direct renin inhibitor, has anti-proteinuric effects. We conducted a randomized crossover study to evaluate the anti-proteinuric effect of aliskiren in patients with immunoglobulin A (IgA) nephropathy. Methods We studied 22 patients with biopsy-proven IgA nephropathy and persistent proteinuria despite angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB). Patients were randomized to either oral aliskiren 300 mg/day or placebo for 16 weeks and then crossed over to the other treatment arm after a washout period. Proteinuria, estimated glomerular filtration rate (eGFR), blood pressure, and serum potassium were monitored. Results After aliskiren treatment, there was a significant reduction in proteinuria in 4 weeks (1.76±0.95 to 1.03±0.69 g:g-Cr, p<0.0001), which remained at a low level throughout the treatment period. There was a significant difference in proteinuria between the aliskiren and placebo groups from 4 to 16 weeks after treatment (p<0.01 for all comparisons). After aliskiren treatment, there were modest but statistically significant reductions in eGFR (57.2±29.1 to 54.8±29.3 ml/min/1.73 m2, p = 0.013) and diastolic blood pressure (72.6±12.3 to 66.2±11.2 mmHg, p<0.0001). None of the patient developed severe hyperkalemia (serum potassium ≥6.0 mmol/l) during the study period. Conclusions Aliskiren has anti-proteinuric effect in patients with IgA nephropathy and persistent proteinuria despite ACE inhibitor or ARB. Further studies are needed to confirm the renal protecting effect of direct renin inhibition in chronic proteinuric kidney diseases. Trial Registration ClinicalTrials.gov NCT00870493
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Affiliation(s)
- Cheuk-Chun Szeto
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China.
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Li PKT, Kwan BCH, Chow KM, Leung CB, Szeto CC. Treatment of early immunoglobulin A nephropathy by angiotensin-converting enzyme inhibitor. Am J Med 2013; 126:162-8. [PMID: 23331443 DOI: 10.1016/j.amjmed.2012.06.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Revised: 06/07/2012] [Accepted: 06/08/2012] [Indexed: 01/13/2023]
Abstract
BACKGROUND The treatment of immunoglobulin A (IgA) nephropathy with normal renal function and minimal proteinuria is unknown. METHODS We randomly assigned 60 patients with IgA nephropathy, proteinuria <0.5 g/day, normal blood pressure and renal function to ramipril 2.5 mg daily or no treatment. Patients were followed for 5 years for the development of hypertension, proteinuria, or impaired renal function. RESULTS The blood pressure of the treatment group was marginally lower than the control group throughout the study period. At 60 months, the event-free survival was marginally higher for the treatment group as compared with the control group (81.1% vs 70.5%, P=.27). The proteinuria-free survival was similar at 82.9% and 79.3% for the treatment and control groups, respectively (P=.6); hypertension-free survival was 86.4% and 79.3% (P=.2). After 60 months of follow-up, the estimated glomerular filtration rate (GFR) was 108.1±29.0 mL/min/1.73 m(2) for the treatment group and 105.7±17.7 mL/min/1.73 m(2) for the control group (P=.7), but the difference was not statistically significant. None of the patients developed impaired renal function. The rate of GFR decline was similar between the treatment and control groups (-0.39±2.57 vs -0.59±1.63 mL/min/1.73 m(2) per year, respectively, P=.7). In general, the study medication was well tolerated. Two patients needed to stop prematurely because of cough and dizziness. CONCLUSION For early IgA nephropathy patients with minimal proteinuria, normal blood pressure, and normal renal function, treatment with 2.5 mg/daily of ramipril for 5 years does not offer any benefit.
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Affiliation(s)
- Philip Kam-Tao Li
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
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Ruggenenti P, Cravedi P, Remuzzi G. Mechanisms and treatment of CKD. J Am Soc Nephrol 2012; 23:1917-28. [PMID: 23100218 DOI: 10.1681/asn.2012040390] [Citation(s) in RCA: 192] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
As CKD continues to increase worldwide, along with the demand for related life-saving therapies, the financial burden of CKD will place an increasing drain on health care systems. Experimental studies showed that glomerular capillary hypertension and impaired sieving function with consequent protein overload play a pathogenic role in the progression of CKD. Consistently, human studies show that proteinuria is an independent predictor of progression and that its reduction is renoprotective. At comparable BP control, inhibitors of the renin-angiotensin system (RAS), including angiotensin converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs), more effectively than non-RAS inhibitor therapy reduce proteinuria, slow progression to ESRD, and even improve the kidney function achieving disease regression in some cases. In participants with diabetes, RAS inhibitors delay the onset of microalbuminuria and its progression to macroalbuminuria, and ACE inhibitors may reduce the excess cardiovascular mortality associated with diabetic renal disease. In addition to RAS inhibitors, however, multimodal approaches including lifestyle modifications and multidrug therapy will be required in most cases to optimize control of the several risk factors for CKD and related cardiovascular morbidity. Whether novel medications may help further improve the cost-effectiveness of renoprotective interventions is a matter of investigation.
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Affiliation(s)
- Piero Ruggenenti
- Mario Negri Institute for Pharmacological Research, Clinical Research Center for Rare Diseases, Aldo e Cele Daccò, Villa Camozzi, Ranica, Italy
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31
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Barbour SJ, Reich HN. Risk stratification of patients with IgA nephropathy. Am J Kidney Dis 2012; 59:865-73. [PMID: 22497792 DOI: 10.1053/j.ajkd.2012.02.326] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2011] [Accepted: 02/09/2012] [Indexed: 12/14/2022]
Abstract
In this review, we summarize recent advances in the risk stratification of patients with immunoglobulin A (IgA) nephropathy. Several clinical variables have consistent and independent associations with worse kidney prognosis, including blood pressure, proteinuria, and baseline kidney function. Although one-time cross-sectional assessments of blood pressure and proteinuria are important, a more thorough understanding of risk can be achieved when these variables are considered over a follow-up period. IgA nephropathy is unique compared with other glomerular diseases in that a much lower threshold of proteinuria (protein excretion, 1 g/d) is associated with glomerular filtration rate (GFR) loss. Controlling proteinuria and blood pressure over time is important to reduce the risk of future loss of kidney function. The recently described Oxford classification has helped standardize the pathologic characterization of IgA nephropathy using a scoring system that is readily reproducible and associated with increased risk of GFR loss independent of clinical variables. We suggest an approach to risk stratification in IgA nephropathy when considering potential treatment with immunosuppression. Despite our current understanding of risk stratification in IgA nephropathy, the ability to accurately predict individual patient-level risk currently is limited, and further research into additional biomarkers or risk prediction tools is needed to improve the care of patients with IgA nephropathy.
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Affiliation(s)
- Sean J Barbour
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
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Vejakama P, Thakkinstian A, Lertrattananon D, Ingsathit A, Ngarmukos C, Attia J. Reno-protective effects of renin-angiotensin system blockade in type 2 diabetic patients: a systematic review and network meta-analysis. Diabetologia 2012; 55:566-78. [PMID: 22189484 PMCID: PMC3268972 DOI: 10.1007/s00125-011-2398-8] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Accepted: 11/07/2011] [Indexed: 12/13/2022]
Abstract
AIMS/HYPOTHESIS This meta-analysis aimed to compare the renal outcomes between ACE inhibitor (ACEI)/angiotensin II receptor blocker (ARB) and other antihypertensive drugs or placebo in type 2 diabetes. METHODS Publications were identified from Medline and Embase up to July 2011. Only randomised controlled trials comparing ACEI/ARB monotherapy with other active drugs or placebo were eligible. The outcome of end-stage renal disease, doubling of serum creatinine, microvascular complications, microalbuminuria, macroalbuminuria and albuminuria regression were extracted. Risk ratios were pooled using a random-effects model if heterogeneity was present; a fixed-effects model was used in the absence of heterogeneity. RESULTS Of 673 studies identified, 28 were eligible (n = 13-4,912). In direct meta-analysis, ACEI/ARB had significantly lower risk of serum creatinine doubling (pooled RR = 0.66 [95% CI 0.52, 0.83]), macroalbuminuria (pooled RR = 0.70 [95% CI 0.50, 1.00]) and albuminuria regression (pooled RR 1.16 [95% CI 1.00, 1.39]) than other antihypertensive drugs, mainly calcium channel blockers (CCBs). Although the risks of end-stage renal disease and microalbuminuria were lower in the ACEI/ARB group (pooled RR 0.82 [95% CI 0.64, 1.05] and 0.84 [95% CI 0.61, 1.15], respectively), the differences were not statistically significant. The ACEI/ARB benefit over placebo was significant for all outcomes except microalbuminuria. A network meta-analysis detected significant treatment effects across all outcomes for both active drugs and placebo comparisons. CONCLUSIONS/INTERPRETATION Our review suggests a consistent reno-protective effect of ACEI/ARB over other antihypertensive drugs, mainly CCBs, and placebo in type 2 diabetes. The lack of any differences in BP decrease between ACEI/ARB and active comparators suggest this benefit is not due simply to the antihypertensive effect.
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Affiliation(s)
- P. Vejakama
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Rama 6 Road, Rachatevi, Bangkok, 10400 Thailand
- Bundarik Hospital, Ubon Ratchathani Province, Thailand
| | - A. Thakkinstian
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Rama 6 Road, Rachatevi, Bangkok, 10400 Thailand
| | - D. Lertrattananon
- Department of Family Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - A. Ingsathit
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Rama 6 Road, Rachatevi, Bangkok, 10400 Thailand
| | - C. Ngarmukos
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - J. Attia
- Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, University of Newcastle and Hunter Medical Research Institute, Newcastle, NSW Australia
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UCHIDA M, SAKAGUCHI Y, MIYAMOTO Y. A Novel Vitamin K 1 2,3-Epoxide Reductase (VKOR) Inhibitor, 3-Acetyl-5-Methyltetronic Acid, Reduces Experimental Glomerulonephritis. J Vet Med Sci 2012; 74:863-9. [DOI: 10.1292/jvms.11-0530] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Masashi UCHIDA
- Toxicology and Pharmacokinetics Laboratories, Pharmaceutical Research Laboratories, Toray Industries, Inc., 6–10–1 Tebiro, Kamakura, Kanagawa 248–8555, Japan
| | - Yuka SAKAGUCHI
- Toxicology and Pharmacokinetics Laboratories, Pharmaceutical Research Laboratories, Toray Industries, Inc., 6–10–1 Tebiro, Kamakura, Kanagawa 248–8555, Japan
| | - Yohei MIYAMOTO
- Toxicology and Pharmacokinetics Laboratories, Pharmaceutical Research Laboratories, Toray Industries, Inc., 6–10–1 Tebiro, Kamakura, Kanagawa 248–8555, Japan
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Proteinuria: detection and role in native renal disease progression. Transplant Rev (Orlando) 2012; 26:3-13. [DOI: 10.1016/j.trre.2011.10.002] [Citation(s) in RCA: 141] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 10/18/2011] [Indexed: 01/13/2023]
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Zoccali C, Ruggenenti P, Perna A, Leonardis D, Tripepi R, Tripepi G, Mallamaci F, Remuzzi G. Phosphate may promote CKD progression and attenuate renoprotective effect of ACE inhibition. J Am Soc Nephrol 2011; 22:1923-30. [PMID: 21852581 DOI: 10.1681/asn.2011020175] [Citation(s) in RCA: 176] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Phosphate may promote the onset and progression of chronic nephropathies. Here we evaluated the relationships between baseline serum phosphate levels, disease progression, and response to ACE inhibition in 331 patients with proteinuric nephropathies in the prospective Ramipril Efficacy In Nephropathy (REIN) trial. Independent of treatment, patients with phosphate levels in the highest two quartiles progressed significantly faster either to ESRD or to a composite endpoint of doubling of serum creatinine or ESRD compared with patients with phosphate levels below the median (P < 0.001). Results were similar when we analyzed phosphate as a continuous variable (P ≤ 0.004). The renoprotective effect of ramipril decreased as serum phosphate increased (P ≤ 0.008 for interaction); this modification of the treatment effect by phosphate persisted despite adjusting for potential confounders such as GFR and urinary protein. In summary, these data suggest that phosphate is an independent risk factor for progression of renal disease among patients with proteinuric CKD, and high levels of phosphate may even attenuate the renoprotective effect of ACE inhibitors. Future trials should test whether reducing serum phosphate improves renal outcomes and optimizes the renoprotective effect of ACE inhibition.
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Affiliation(s)
- Carmine Zoccali
- Nephrology, Dialysis and Transplantation Unit, Ospedali Riuniti, Reggio Calabria, Italy.
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Importance and benefits of dietary sodium restriction in the management of chronic kidney disease patients: experience from a single Chinese center. Int Urol Nephrol 2011; 44:549-56. [DOI: 10.1007/s11255-011-9986-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Accepted: 04/29/2011] [Indexed: 11/26/2022]
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Manns B, Hemmelgarn B, Tonelli M, Au F, Chiasson TC, Dong J, Klarenbach S. Population based screening for chronic kidney disease: cost effectiveness study. BMJ 2010; 341:c5869. [PMID: 21059726 PMCID: PMC2975430 DOI: 10.1136/bmj.c5869] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine the cost effectiveness of one-off population based screening for chronic kidney disease based on estimated glomerular filtration rate. DESIGN Cost utility analysis of screening with estimated glomerular filtration rate alone compared with no screening (with allowance for incidental finding of cases of chronic kidney disease). Analyses were stratified by age, diabetes, and the presence or absence of proteinuria. Scenario and sensitivity analyses, including probabilistic sensitivity analysis, were performed. Costs were estimated in all adults and in subgroups defined by age, diabetes, and hypertension. SETTING Publicly funded Canadian healthcare system. PARTICIPANTS Large population based laboratory cohort used to estimate mortality rates and incidence of end stage renal disease for patients with chronic kidney disease over a five year follow-up period. Patients had not previously undergone assessment of glomerular filtration rate. MAIN OUTCOME MEASURES Lifetime costs, end stage renal disease, quality adjusted life years (QALYs) gained, and incremental cost per QALY gained. RESULTS Compared with no screening, population based screening for chronic kidney disease was associated with an incremental cost of $C463 (Canadian dollars in 2009; equivalent to about £275, €308, US $382) and a gain of 0.0044 QALYs per patient overall, representing a cost per QALY gained of $C104 900. In a cohort of 100 000 people, screening for chronic kidney disease would be expected to reduce the number of people who develop end stage renal disease over their lifetime from 675 to 657. In subgroups of people with and without diabetes, the cost per QALY gained was $C22 600 and $C572 000, respectively. In a cohort of 100 000 people with diabetes, screening would be expected to reduce the number of people who develop end stage renal disease over their lifetime from 1796 to 1741. In people without diabetes with and without hypertension, the cost per QALY gained was $C334 000 and $C1 411 100, respectively. CONCLUSIONS Population based screening for chronic kidney disease with assessment of estimated glomerular filtration rate is not cost effective overall or in subgroups of people with hypertension or older people. Targeted screening of people with diabetes is associated with a cost per QALY that is similar to that accepted in other interventions funded by public healthcare systems.
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Affiliation(s)
- Braden Manns
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
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38
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Leyva de la Torre C, Furones Mourelle J, Heras A, Dávalos Iglesias J. Bloqueadores del sistema renina angiotensina en pacientes con nefropatía por IgA: metanálisis de ensayos clínicos controlados. HIPERTENSION Y RIESGO VASCULAR 2010. [DOI: 10.1016/j.hipert.2010.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Udayaraj UP, Casula A, Ansell D, Dudley CRK, Ravanan R. Chronic kidney disease in kidney transplant recipients-is it different from chronic native kidney disease? Transplantation 2010; 90:765-70. [PMID: 20686443 DOI: 10.1097/tp.0b013e3181f00a04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND The rate of change in estimated glomerular filtration rate (ΔeGFR), factors influencing ΔeGFR, and its association with mortality has not been well studied in renal transplant recipients. METHODS.: Adult kidney-only recipients between January 2001 and December 2004, with surviving grafts 1 year after transplantation, from England and Wales were followed up till 31 December 2006, graft failure or death. The four variable modification of diet in renal disease equation was used to estimate GFR and ΔeGFR assessed using linear least square regression. ΔeGFR of -1 mL/min/1.73m per year and above was considered to be stable or improving function. Linear regression and Cox regression analyses were used to examine factors influencing ΔeGFR and its association with mortality, respectively. RESULTS Of the 2, 927 patients included, ΔeGFR was -1.3±6.0 mL/min/1.73 m per year and eGFR remained stable or improved in the majority (54.8%). Baseline graft function at 1 year or live donor status did not influence ΔeGFR. Male donor to female recipient transplantation, younger recipients, diabetes, white race, and human leukocyte antigen mismatch were associated with faster decline in eGFR. ΔeGFR was not associated with mortality when censored for graft failure. CONCLUSIONS Majority of renal transplant recipients experienced stable or improved graft function. Specific donor and recipient characteristics influenced the rate of decline in eGFR. The lack of association of ΔeGFR with mortality, the stability of eGFR in the majority, and influence of donor characteristics on ΔeGFR suggest caution when applying prognosis knowledge from the native kidney disease to the kidney transplant population.
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Affiliation(s)
- Udaya P Udayaraj
- Richard Bright Renal Unit, Southmead Hospital, Southmead Road, Bristol, United Kingdom.
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40
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Batista EC, Carvalho LR, Casarini DE, Carmona AK, dos Santos EL, da Silva ED, dos Santos RA, Nakaie CR, Rojas MVM, de Oliveira SM, Bader M, D'Almeida V, Martins AM, de Picoly Souza K, Pesquero JB. ACE activity is modulated by the enzyme α-galactosidase A. J Mol Med (Berl) 2010; 89:65-74. [PMID: 20941593 DOI: 10.1007/s00109-010-0686-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Revised: 09/07/2010] [Accepted: 09/13/2010] [Indexed: 01/13/2023]
Abstract
Fabry disease is a multisystem X-linked disorder resulting from α-galactosidase A (α-GalA) gene mutations leading to the accumulation of globotriaosylceramide mainly in endothelium compromising heart, kidney, and brain. In Fabry patients, progressive renal failure is frequently treated with angiotensin I-converting enzyme (ACE) inhibitors. We were interested in the possible interactions between ACE inhibitors therapy and the only causative therapy for Fabry disease, the enzyme replacement therapy (ERT) using recombinant human α-GalA (rhα-GalA). Our results suggest that ACE activity was significantly inhibited in plasma of Fabry patients and the blood pressure level decreased just after ERT (at the end of the rhα-GalA infusion). Interestingly, 2 weeks later, ACE activity was significantly upregulated and the plasma levels of angiotensin II increased in the patients treated with rhα-GalA following the elevations of ACE activity. The same inhibitory effect on ACE activity was also observed in rats after rhα-GalA infusion. Furthermore, ACE activity in CHO cells transfected with the human ACE was inhibited dose and time-dependently by rhα-GalA. In vitro, the incubation of plasma from healthy volunteers with rhα-GalA significantly reduced ACE activity. Finally, rhα-GalA also inhibited ACE activity and released galactose residues from purified rabbit lung ACE dose-dependently. In summary, our results suggest that rhα-GalA interacts with ACE and inhibits its activity, possibly by removing the galactose residues from the enzyme. This modulation might have profound impact on the clinical outcome of Fabry patients treated with rhα-GalA.
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McQuarrie EP, Patel RK, Mark PB, Delles C, Connell J, Dargie HJ, Steedman T, Jardine AG. Association between proteinuria and left ventricular mass index: a cardiac MRI study in patients with chronic kidney disease. Nephrol Dial Transplant 2010; 26:933-8. [DOI: 10.1093/ndt/gfq418] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Furth S. Blood pressure control and progression of CKD in children. Am J Kidney Dis 2010; 55:988-91. [PMID: 20417000 DOI: 10.1053/j.ajkd.2010.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Accepted: 03/15/2010] [Indexed: 01/13/2023]
Affiliation(s)
- Susan Furth
- Division of Nephrology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104-4399, USA.
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Wühl E, Trivelli A, Picca S, Litwin M, Peco-Antic A, Zurowska A, Testa S, Jankauskiene A, Emre S, Caldas-Afonso A, Anarat A, Niaudet P, Mir S, Bakkaloglu A, Enke B, Montini G, Wingen AM, Sallay P, Jeck N, Berg U, Caliskan S, Wygoda S, Hohbach-Hohenfellner K, Dusek J, Urasinski T, Arbeiter K, Neuhaus T, Gellermann J, Drozdz D, Fischbach M, Möller K, Wigger M, Peruzzi L, Mehls O, Schaefer F. Strict blood-pressure control and progression of renal failure in children. N Engl J Med 2009; 361:1639-50. [PMID: 19846849 DOI: 10.1056/nejmoa0902066] [Citation(s) in RCA: 514] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although inhibition of the renin-angiotensin system delays the progression of renal failure in adults with chronic kidney disease, the blood-pressure target for optimal renal protection is controversial. We assessed the long-term renoprotective effect of intensified blood-pressure control among children who were receiving a fixed high dose of an angiotensin-converting-enzyme (ACE) inhibitor. METHODS After a 6-month run-in period, 385 children, 3 to 18 years of age, with chronic kidney disease (glomerular filtration rate of 15 to 80 ml per minute per 1.73 m(2) of body-surface area) received ramipril at a dose of 6 mg per square meter of body-surface area per day. Patients were randomly assigned to intensified blood-pressure control (with a target 24-hour mean arterial pressure below the 50th percentile) or conventional blood-pressure control (mean arterial pressure in the 50th to 95th percentile), achieved by the addition of antihypertensive therapy that does not target the renin-angiotensin system; patients were followed for 5 years. The primary end point was the time to a decline of 50% in the glomerular filtration rate or progression to end-stage renal disease. Secondary end points included changes in blood pressure, glomerular filtration rate, and urinary protein excretion. RESULTS A total of 29.9% of the patients in the group that received intensified blood-pressure control reached the primary end point, as assessed by means of a Kaplan-Meier analysis, as compared with 41.7% in the group that received conventional blood-pressure control (hazard ratio, 0.65; confidence interval, 0.44 to 0.94; P=0.02). The two groups did not differ significantly with respect to the type or incidence of adverse events or the cumulative rates of withdrawal from the study (28.0% vs. 26.5%). Proteinuria gradually rebounded during ongoing ACE inhibition after an initial 50% decrease, despite persistently good blood-pressure control. Achievement of blood-pressure targets and a decrease in proteinuria were significant independent predictors of delayed progression of renal disease. CONCLUSIONS Intensified blood-pressure control, with target 24-hour blood-pressure levels in the low range of normal, confers a substantial benefit with respect to renal function among children with chronic kidney disease. Reappearance of proteinuria after initial successful pharmacologic blood-pressure control is common among children who are receiving long-term ACE inhibition. (ClinicalTrials.gov number, NCT00221845.)
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Abstract
Candesartan doses in excess of the recommended antihypertensive maxima have been reported to lead to greater reductions of proteinuria than the advised doses. High-dose angiotensin-converting-enzyme inhibitors, however, are at least as effective as high-dose angiotensin blockers and less expensive. Angiotensin-converting-enzyme inhibition is thus the first-line strategy to halt kidney disease progression.
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Abstract
Immunoglobulin A nephropathy (IgAN) is the most commonly encountered primary glomerulonephritis and it usually follows an indolent clinical course. However, hypertensive patients with proteinuria and renal insufficiency at presentation and patients with severe histological involvement are at high risk to develop end stage renal failure. There is no consensus for the treatment of patients with IgA nephropathy. In general, patients with normal renal function, mild proteinuria (<I g/24 h) and mild histopathological involvement need only observation, whereas patients with heavy proteinuria, impaired renal function and moderate to severe histopathological involvement are candidates for specific treatment. Angiotensin converting enzyme (ACE) inhibitors are used in patients with arterial hypertension and/or proteinuria 1-2 g/24 h. Corticosteroids are indicated in patients with heavy proteinuria (>3 g/24 h) and in progressive disease despite treatment with ACE inhibitors. Fish oil might be an alternative to corticosteroids in cases with renal insufficiency and chronic histological lesions. Combinations of corticosteroids and cytotoxic drugs are saved for patients with IgA nephropathy and a rapidly progressive course.
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Affiliation(s)
- Dimitrios S Goumenos
- Department of Internal Medicine--Nephrology, University Hospital, Patras, Greece.
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46
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SUZUKI HIROMICHI, KANNO YOSHIHIKO, NAKAMOTO HIDETOMO, OKADA HIROKAZU, SUGAHARA SOUICHI. Decline of Renal Function Is Associated with Proteinuria and Systolic Blood Pressure in the Morning in Diabetic Nephropathy. Clin Exp Hypertens 2009. [DOI: 10.1081/ceh-48735] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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47
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Wang Y, Zhang L, Li X, Xu Y, Yang M, Qian J, Wang L, Chen N, Gu Y, Chen M, Xing C, Chen X, Hou F, Yu X, Cheng X, Guo L, Wei C, Huang G, Zhang Q, Wang R, Wang L, Mei C, Li Y, Liu Z, Zhao L, Wu Y, Wang HY. Improvement of awareness, treatment and control of hypertension among chronic kidney disease patients in China from 1999 to 2005. Hypertens Res 2009; 32:444-9. [DOI: 10.1038/hr.2009.38] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Complementary effects of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in slowing the progression of chronic kidney disease. Am Heart J 2009; 157:S7-S16. [PMID: 19450722 DOI: 10.1016/j.ahj.2009.04.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Chronic kidney disease (CKD) and end-stage renal disease continue to pose major healthcare challenges. Early initiation of therapy aimed at slowing the progression of CKD is essential. Increased renin-angiotensin-aldosterone-system activity and, in particular, elevated levels of angiotensin II (AII) play important roles in the development and progression of CKD. Therefore, pharmacologic therapies that block the effects of AII and reduce its pathogenic effects are cornerstones of clinical management. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) have been shown to have renoprotective effects in addition to their ability to control blood pressure. There is accumulating clinical evidence that the combination of an ACEI and an ARB provides greater renal protection, particularly in decreasing proteinuria, than does either agent alone.
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Cheng J, Zhang W, Zhang XH, He Q, Tao XJ, Chen JH. ACEI/ARB therapy for IgA nephropathy: a meta analysis of randomised controlled trials. Int J Clin Pract 2009; 63:880-8. [PMID: 19490198 DOI: 10.1111/j.1742-1241.2009.02038.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Published reports examining the efficacy of RAS blockers: angiotensin converting-enzyme inhibitor (ACEI) and angiotensin II receptor blocker (ARB) agents for preserving renal function in IgA nephropathy (IgAN) have yielded conflicting results. To evaluate systematically the effects of ACEI/ARB agents on IgAN, we conducted a meta analysis of published randomised controlled trials (RCTs). METHODS MEDLINE, EMBASE, the Cochrane Library and article reference lists were searched for RCTs that compared ACEI/ARB with placebo and any other antihypertensive agents or non-immunosuppressive agents for treating IgAN. The quality of the studies was evaluated with the method of intention to treat analysis and allocation concealment, as well as with the Jadad method. Meta analyses were performed on the outcomes of proteinuria and renal function in patients with IgAN. RESULTS Eleven RCTs involving 585 patients were included in the review. Seven trials used placebo/no treatment as controls. Four trials used other antihypertensive agents as controls. Overall, ACEI/ARB agents had statistically significant effects on protecting renal function(p < 0.00001) and reduction of proteinuria (p < 0.00001) when compared with control group. Tests for heterogeneity showed no difference in effect among the studies. Systolic and diastolic blood pressure, glomerular filtration rate (GFR), age, did not influence treatment response. ACEI/ARB agents were well tolerated. CONCLUSIONS The current cumulative evidence suggests that ACEI/ARB agents had statistically significant effects on protecting renal function and reduction of proteinuria in patients with IgAN when compared with control groups. ACEI/ ARB agents are a promising medication and should be investigated further.
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Affiliation(s)
- J Cheng
- Kidney Disease Center of the First Affiliated Hospital, Medical School of Zhejiang University, Hangzhou, China
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50
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Szeto CC, Li PKT. The use of vitamin D analogues in chronic kidney diseases: possible mechanisms beyond bone and mineral metabolism. NDT Plus 2009; 2:205-12. [PMID: 25983993 PMCID: PMC4421197 DOI: 10.1093/ndtplus/sfp034] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2009] [Accepted: 03/03/2009] [Indexed: 12/31/2022] Open
Abstract
Chronic kidney disease (CKD) is a common and costly medical condition, and currently available therapeutic options remain unsatisfactory. Vitamin D analogues are widely used for the bone and mineral disorder associated with CKD. However, accumulating evidence suggests that vitamin D analogues may have actions other than their effects on bone and mineral metabolism. In this article, we review the following aspects on the use of vitamin D analogues for the treatment of CKD: (1) epidemiological studies showing that patients with late-stage CKD have better survival than untreated patients; (2) animal studies showing that vitamin D analogues may retard the progression of CKD; (3) human studies on the anti-proteinuric and possibly renal protecting effects of vitamin D analogues in CKD and (4) the potential mechanisms of its therapeutic benefit. Nonetheless, definitive proof of the clinical benefits by randomized control trial would be necessary before one could advocate the routine use of vitamin D analogues for the treatment of CKD patients.
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Affiliation(s)
- Cheuk-Chun Szeto
- Department of Medicine and Therapeutics , Prince of Wales Hospital, The Chinese University of Hong Kong , Shatin, Hong Kong , China
| | - Philip Kam-Tao Li
- Department of Medicine and Therapeutics , Prince of Wales Hospital, The Chinese University of Hong Kong , Shatin, Hong Kong , China
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