Comparison of Steroids and Angiotensin Receptor Blockers for Patients with Advanced IgA Nephropathy and Impaired Renal Function

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Abstract

Background/Aims: The therapeutic strategy for advanced IgA nephropathy patients with impaired renal function is still controversial. Patients and Methods: We divided 44 IgA nephropathy patients with an estimated glomerular filtration rate (eGFR) of less than 60 ml/min/1.76 m<sup>2</sup> and proteinuria greater than 0.5 g/g · creatinine into two groups: the angiotensin receptor blocker (ARB) group (n = 22), treated with ARBs, and the steroid group (n = 22), treated with corticosteroid. We analyzed the clinical and histological background, renal survival rate until progression to end-stage renal disease (ESRD), and the risk factors for progression. Results: The clinical and histological backgrounds were not significantly different between the groups. At 1 and 2 years after treatment, proteinuria tended to be decreased from baseline in both groups, but not significantly, and urinary red blood cells were significantly decreased in the steroid groups (p < 0.001), but not in the ARB group. The eGFR tended to be increased in the steroid group and decreased in the ARB group. However, the renal survival rate until ESRD was not significantly different between the groups. There were no significant independent risk factors for progression. Conclusion: The beneficial effect of ARBs on renal survival of advanced IgA nephropathy with impaired renal function is equal to that with steroids.

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Most cited references 14

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Remission of proteinuria improves prognosis in IgA nephropathy.

Heather N. Reich, Stéphan Troyanov, James W. Scholey … (2007)

Proteinuria has been shown to be an adverse prognostic factor in IgA nephropathy. The benefit of achieving a partial remission of proteinuria, however, has not been well described. We studied 542 patients with biopsy-proven primary IgA nephropathy in the Toronto Glomerulonephritis Registry and found that glomerular filtration rate (GFR) declined at -0.38 +/- 0.61 ml/min per 1.73 m2/mo overall, with 30% of subjects reaching end-stage renal disease. Multivariate analysis revealed that proteinuria during follow-up was the most important predictor of the rate of GFR decline. Among the 171 patients with 3 g/d (n = 121) lost renal function 25-fold faster than those with or =3 g/d who achieved a partial remission (<1 g/d) had a similar course to patients who had < or =1 g/d throughout, and fared far better than patients who never achieved remission. These results underscore the relationship between proteinuria and prognosis in IgA nephropathy and establish the importance of remission.

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Predicting the risk for dialysis or death in IgA nephropathy.

Francois Berthoux, Hesham Mohey, Blandine Laurent … (2011)

For the individual patient with primary IgA nephropathy (IgAN), it remains a challenge to predict long-term outcomes for patients receiving standard treatment. We studied a prospective cohort of 332 patients with biopsy-proven IgAN patients followed over an average of 13 years. We calculated an absolute renal risk (ARR) of dialysis or death by counting the number of risk factors present at diagnosis: hypertension, proteinuria ≥1 g/d, and severe pathologic lesions (global optical score, ≥8). Overall, the ARR score allowed significant risk stratification (P < 0.0001). The cumulative incidence of death or dialysis at 10 and 20 years was 2 and 4%, respectively, for ARR=0; 2 and 9% for ARR=1; 7 and 18% for ARR=2; and 29 and 64% for ARR=3, in adequately treated patients. When achieved, control of hypertension and reduction of proteinuria reduced the risk for death or dialysis. In conclusion, the absolute renal risk score, determined at diagnosis, associates with risk for dialysis or death. Copyright © 2011 by the American Society of Nephrology

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Mycophenolate mofetil (MMF) vs placebo in patients with moderately advanced IgA nephropathy: a double-blind randomized controlled trial.

Julie Lin, D A Valeri, J Crew … (2005)

IgA nephropathy (IgAN) is the most common form of glomerulonephritis worldwide. Up to 40% progress to end-stage renal disease (ESRD) over 10-20 years. Currently, treatment is limited. We studied the use of mycophenolate mofetil (MMF) vs placebo in a group of North American IgAN patients at high risk for progressive disease. Included were 32 patients aged 18-75 years from multiple centres who had their biopsies read at Columbia and who had at least 1 g of proteinuria per day plus at least two of the following risk factors: (i) male sex; (ii) hypertension >150/90 mmHg or requiring antihypertensive medications; (iii) creatinine clearance, measured by 24 h urine collection, 20 ml/min at time of enrolment; and (iv) presence of glomerulosclerosis or tubulointerstitial atrophy and fibrosis on renal biopsy. Patients were randomized to either 1 year of MMF, titrated up to a dose of 1000 mg bid, or placebo. Total follow-up was 2 years. All patients received angiotensin inhibition medication. The primary outcome was a 50% increase in baseline serum creatinine (SCr). Secondary outcomes were an increase of 0.5 mg/dl SCr, ESRD and a 50% reduction in proteinuria. The mean baseline SCr was 2.4 mg/dl. No statistically significant differences were observed for any outcome. Five of 17 who received MMF vs two of 15 patients in the placebo group reached a 50% increase in SCr (P = 0.4). In both groups, all patients who reached the primary outcome also reached ESRD. Ten who received MMF vs seven who received placebo had a 0.5 mg/dl increase in SCr (P = 0.7) Only three MMF and two placebo patients had a 50% reduction in 24 h proteinuria. No serious adverse events occurred in either group. No benefit was seen in patients who received MMF in this high risk group, probably reflecting the relatively advanced stage of disease of our population. We conclude that MMF is probably not effective in patients with IgAN who already have moderate renal insufficiency.

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Author and article information

Journal

Journal ID (publisher-id): AJN

Journal ID (nlm-ta): Am J Nephrol

Journal ID (doi): 10.1159/issn.0250-8095

Title: American Journal of Nephrology

Publisher: S. Karger AG

ISSN (Print): 0250-8095

ISSN (Electronic): 1421-9670

Publication date Subscription-year: 2011

Publication date (Print): September 2011

Publication date (Electronic): 22 July 2011

Volume: 34

Issue: 3

Pages: 233-240

Affiliations

Department of Medicine, Kidney Center, Tokyo Women’s Medical University, Tokyo, Japan

Author notes

*Takahito Moriyama, MD, PhD, Department of Medicine, Kidney Center, Tokyo Women’s Medical University, Kawada-cho 8-1, Shinjyuku-ku, Tokyo 162-8666 (Japan), Tel. +81 3 3353 8111, E-Mail takamori@kc.twmu.ac.jp

Article

Publisher ID: 330189 Other ID: Am J Nephrol 2011;34:233–240

DOI: 10.1159/000330189

PubMed ID: 21778707

SO-VID: 18f55dc4-3bf8-4ae6-ab46-35244876aaaf

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Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

History

Date received : 14 April 2011

Date accepted : 02 June 2011

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Figures: 2, Tables: 5, Pages: 8

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Comparison of Steroids and Angiotensin Receptor Blockers for Patients with Advanced IgA Nephropathy and Impaired Renal Function

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Abstract

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Karger: Nephrology

Most cited references 14

Remission of proteinuria improves prognosis in IgA nephropathy.

Predicting the risk for dialysis or death in IgA nephropathy.

Mycophenolate mofetil (MMF) vs placebo in patients with moderately advanced IgA nephropathy: a double-blind randomized controlled trial.

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