Hiromichi Yoshida1, Kazuaki Nakajima2, Shigeru Hasegawa3, Shunichi Yamamoto1, Takashi

Supplementation with hydrochlorothiazide maintained immunosuppressant induced remission in the patients with frequently relapsing nephrotic syndrome

Hiromichi Yoshida1, Kazuaki Nakajima2, Shigeru Hasegawa3, Shunichi Yamamoto1, Takashi Tabe1, Haruyuki Hayashi2 and Yasubumi Irie1

1 Department of Nephrology and 2 Department of Surgery, San-ai Memorial Hospital, Chiba, Japan 3 Department of Nephrology, Chiba Social Insurance Hospital, Chiba, Japan

Corresponding author: Dr. Hiromichi Yoshida, Address: 2-3 Shinden-cho, Chuo-ku, Chiba (260-0027), Japan E-mail: hiro519 @ wind .ocn.ne.jp; Tel.: +81-43-246-2271; Fax: +81-43-248-6807

Running title: membranous nephropathy treated by thiazide Word count: for the abstract, 169; for the body of the manuscript, 1504

1 We declare that we have received no financial support and have no conflicts of interest pertaining to this study.

2 Abstract The present case study was constructed to examine the efficacy of a hydrochrolothiazide (HCT) regimen added to prednisolone or/and cyclosporine A (PSL-

CsA), in frequently relapsing nephrotic syndrome of biopsy-proven cases of membranous glomerulonephritis (MGN). Starting or reconstructed treatment with PSL-CsA combined with renin angiotensin system blockade led to complete, or partial remission with proteinuria from 0.2 g/d to 1.0 g/d. However, there were over 4 relapses with proteinuria ranging from 4.0 g/d to 19.9 g/d when PSL-CsA was carefully reduced following each remission. On remission, HCT was supplemented to the minimum dose of PSL-CsA that induced remission. When sustained remission after HCT supplementation was ascertained, we continued with the careful reduction of the maintenance dose of PSL-CsA in 6 out of 7 cases. In 1 case HCT was discontinued because of deterioration of glucose tolerance. The study on our patient population suggests that HCT could have an unconventional mode of antiproteinuric effect and allow reduction of maintenance dose of PSL-CsA in patients with frequent relapsing nephrotic syndrome of MGN.

3 Key words membranous nephropathy－hydrochlorothiazide－spontaneous remission

4 Introduction

Antiproteinuric treatment is a well recognized strategy for renal protection from progression of chronic kidney disease [1, 2]. In primary nephrotic syndrome, it includes corticosteroid, immunosuppresants, cytotoxic agents, and also supportive agents that are associated with inhibiting the renin angiotensin system (RAS). However, nephrologists frequently encounter difficulties in sustaining long-term remission because of resistance to the regimens, or many relapses after dose reduction of the antiproteinuric agents.

Therefore, long-term regimens could cause various adverse effects during the treatment of the disease.

Hydrochrolothiazide (HCT) was reported to exert an antiproteinuric effect secondary to altering the status of body sodium, or declining blood pressure [3, 4, 5].

Inasmuch as its antiproteinuric effect extends widely in various renal diseases, limitations of the effect have been noted [3, 4]. We recently encountered a patient with steroid- resistant nephrotic syndrome that originated from a biopsy-proven membranous glomerulonephritis (MGN), in whom only a high dose of cyclosporine-A (CsA) could

5 sustain complete remission after many relapses, and HCT supplementation was followed by successful reduction of CsA for complete remission. Based on this unusual case, we studied the increased number of patients with high rate of relapses to ascertain whether or not HCT has a beneficial on nephrotic proteinuria in MGN.

6 Patients and methods

The patients were eligible for the study if their nephrotic syndrome with biopsy-proven MGN had relapsed over four times after the first remission by the treatment with prednisolone or/and cyclosporine A (PSL-CsA) (Table 1). The histopathology of MGN was assessed by the Ehrenreich-Churg Classification from stages

I to IV, and with complicated interstitial lesions consisting of cell infiltration and/or fibrosis indicated by － to +++. The dose of PSL-CsA was decreased carefully while sustaining remission. Each patient had many relapses while being tapered from the fixed doses of PSL-CsA that were associated with the remissions. RAS blockades were combined with PSL-CsA to treat hypertension and also aimed for a renoprotective effect.

HCT at 12.5 or 25 mg/d was supplemented when the patients were at remission lasting for at least 2 weeks at the minimum dose of PSL-CsA. Two weeks after HCT supplementation, we began to reduce PSL-CsA carefully. The assessment of the effectiveness of HCT addition was carried out when PSL-CsA dose reached 0 to 33% of baseline corresponding to the minimum dose of the drug. Clinical examinations involved

7 blood pressure (BP), serum creatinine, daily urine protein, and fractional excretion of sodium (FENa). They were performed just before HCT supplementation, and at 2 weeks after every reduction of PSL-CsA combined with HCT. The clinical findings after HCT supplementation are shown at the latest dose of PSL-CsA in Table 2. During the treatment, patients were advised to have a dietary salt intake of about 7 g/d regularly.

8 Results

Histopathologic study revealed stage III of the Ehrenreich-Churg Classification with moderate interstitial lesions in case 1. In the other 5 cases mild histological changes were observed. In case 1 nephrotic syndrome was completely resistant against prednisolone (PSL), and in case 2 PSL was contraindicated due to the remarkable elevation of intraocular pressure. In case 3 CsA was discontinued halfway during the treatment due to severe gingival thickness. In case 4, because of frequent relapses during monotherapy with PSL, CsA was used in combination. The monotherapy with mizorivine had no antiproteinuric benefits in cases 1 and 2, and was discontinued due to severe diarrhea in case 4 and moderate liver dysfunction in case 6. The combined use of RAS blockades did not work in synergy with PSL-CsA. After PSL-CsA was supplemented with HCT, the maintenance dose of PSL-CsA was actually decreased without any relapse

(Table 2). CsA in case 2 and PSL in case 5 were completely discontinued. The values of

FENa were increased in every case. Serum creatinine increased slightly in cases 3, 4, and

5. BP decline was not significant after HCT supplementation in all patients. The term of

9 12 -27 months was required for reduction of PSL-CsA to the latest maintenance doses since HCT was administered (data not shown).

10 Discussion

Our first impression in case 1 was that the successful reduction of the maintenance dose might be due to natural remission. To investigate whether HCT supplementation actually exerted a PSL-CsA reducing effect, we proceeded to study 7 additional MGN patients in whom reduction of PSL-CsA caused frequent relapses and long-term treatments with moderate to high-doses PSL-CsA were essential for maintaining remission. HCT supplementation in 6 of 7 patients studied was successful in further reduction of maintenance dose, but one patient was excluded because of deterioration of glucose tolerance. It is our belief that the clinical finding in the 5 additional cases supports the idea that HCT could reduce CsA dose that was observed in case 1.

Several studies have described an anti-proteinuric effect that was thought to be

associated with alteration of body sodium status [3, 4, 5, 6, 7]. Dietary sodium

restriction or diuretic treatment equally enhances the antiproteinuric effect of RAS

blockades [3]. The added effect of HCT on proteinuria was associated with lowering

11 BP, whereas this was not the case for the added effect of a low sodium diet, suggesting different modes of action. There is experimental evidence that although the effects of sodium restriction and HCT might not be equivalent, both act on sodium status [6]. In uninephrectomized SHR rats, a model for hypertension and proteinuria, sodium restriction but not diuretic therapy diminished renal hypertrophy, whereas BP was not affected. Increased proteinuria due to high sodium intake has been reported to be restored by co-treatment with HCT in several glomerulopathies on chronic ACE inhibition [4]. In this study, addition of HCT resulted in a 10% reduction in BP, whereas there was a 40% reduction in proteinuria. Buter et al. argue that after HCT supplementation, the antiproteinuric effect to an ACE inhibitor cannot be explained solely by lowering BP. In IgA nephritis treated with angiotensin II modulators, there is a decline in nocturnal BP, which in turn lowers elevated glomerular capillary pressure.

This emphasizes the role of thiazide in contributing to an antiproteinuric effect [5].

Thus the mechanism regarding antiproteinuric and renoprotective effects of thiazide remains uncertain in terms of BP decline. In our patients BP decline by HCT was not

12 significant, and alteration of body sodium status was as indicated by the increase of

urine sodium excretion. Therefore, the reducing effect of PSL-CsA cannot be explained

by BP decline, and body sodium alteration is ambiguous as a precise factor from the

limited findings provided.

There exists the possibility that our patients might have undergone spontaneous remission. Spontaneous remission has been noted to occur in 20–30% of MGN patients, with the rest progressing to end-stage kidney failure [8]. Nephrotic-range proteinuria is thought to have a negative effect for a spontaneous remission. Disease progression is also associated with other factors including male gender, reduced renal function, interstitial lesion, hyperlipidemia, and hypoalbuminemia [9, 10]. Recently a retrospective, multicenter cohort study of MGN patients conducted by Polanco et al. determined the spontaneous remission rate of the disease [11]. They concluded that a significant number of MGN patients with nephrotic syndrome (31.7%) develop spontaneous remission and have an excellent long-term outcome. Moreover, a decrease in proteinuria by 50% of baseline during the first year significantly predicts the appearance of spontaneous

13 remission. They also emphasized that immunosuppressive therapy should be considered without delay for patients without a significant decrease in proteinuria during the first year if the baseline proteinuria was over 8 g/d. This study is of value in that nephrotic syndrome had been followed without treatment during the first year even though urinary protein excretion was over 12 g/d. It is probable that the frequent relapses noted during the long terms of disease in our patients would not be considered as examples of natural remission by Polanco et al [11].

Of particular interest is the fact that HCT was not administered in the relapsed phase, but in the remission phase with minimum dose of PSL-CsA and RAS blockades.

We ascertained in advance that monotherapy or supplementation of HCT given in the relapsed phase did not show any anti-proteinuric effect. Vogt et al. reported that HCT alone does not influence proteinuria [12], whereas intensified intervention of sodium status by diuretics is an effective tool to strengthen the antiproteinuric effect of RAS blockades [3, 5]. Conceivably then, HCT given in remission with RAS blockades, might exert an antiproteinuric action that affects PSL-CsA by a different mechanism from what

14 is known of its pharmacology.

In summary our study demonstrated that HCT supplementation achieved long- term remission with a lower dose of PSL-CsA combined with RAS blockades in 6 patients with MGN in whom there were difficulties in reducing the maintenance dose of

PSL-CsA due to repeated relapses of nephrotic syndrome. Although thiazide has been used worldwide for five decades for hypertension, cardiovascular diseases, and chronic kidney diseases, we propose that HCT might be listed as a drug that could be a trigger on antiproteinuric action in MGN. However further investigations in a large population of patients or other nephrotic type kidney diseases are warranted to confirm its antiproteinuric effect.

15 References

[1] Ruggenenti P, Schieppati A, Remuzzi G. Progression, remission, regression of

chronic renal diseases. Lancet. 2001; 357: 1601-1608.

[2] Remuzzi G, Perico N, Macia M, Ruggenenti P. The role of renin-angiotensin-

aldosterone system in the progression of chronic kidney disease. Kidney Int. 2005;

68(suppl ): S57-S65.

[3] Vogt L, Waanders F, Boomsma F, de Zeeuw D, Navis G. Effects of dietary sodium and

hydrochlorothiazide on the antiproteinuric efficacy of losartan. J Am Soc Nephrol.

2008; 19: 999-1007.

[4] Buter H, Hemmelder MH, Navis G, de Jong PE, de Zeeuw D. The blunting of the

antiproteinuric efficacy of ACE inhibition by high sodium intake can be restored by

hydrochlorothiazide. Nephrol Dial Transplant. 1998; 13: 1682-1685.

[5] Uzu T, Harada T, Namba T, Yamamoto R, Takahara K, Yamauchi A, Kimura G..

Thiazide diuretics enhance nocturnal blood pressure fall and reduce proteinuria in

immunoglobulin A nephropathy treated with angiotensin II modulators. J

16 Hypertens. 2005; 23: 861-865.

[6] Fujihara CK, Malheiros DM, Zatz R. Losartan-hydrochrolothiazide association

promotes lasting blood pressure normalization and completely arrests long-term

renal injury in the 5/6 ablation model. Am J Physiol Renal Physiol. 2007; 292:

F1810-F1818.

[7] Dussol B, Moassi-Frances J, Morange S, Somma-Delpero C, Mundler O, Berland Y.

A randomized trial of furosemide vs hydrochlorothiazide in patients with chronic

renal failure and hypertension. Nephrol Dial Transplant. 2005; 20: 349-353.

[8] Laluck BJ Jr, Cattran DC. Prognosis after a complete remission in adult patients

with idiopathic membranous nephropathy. Am J Kidney Dis. 1999; 33: 1026-1032.

[9] Glassock RJ. Diagnosis and natural course of membranous nephropathy. Semin

Nephrol. 2003; 23: 324-332.

[10] Wehrmann M, Bohle A, Bogenschütz O, Eissek R, Freisledorer A, Ohlschlegel C,

Schumm G, Batz C, Gärtner HV. Long-term prognosis of chronic idiopathic

membranous glomerulonephritis. An analysis 334 cases with particular regard to

tubulo-interstitial changes. Clin Nephrol. 1989; 31: 67-76.

17 [11] Polanco N, Gutiérrez E, Covarsí A, Ariza F, Carreño A, Vigil A, Baltar J,

Fernández-Fresnedo G, Martín C, Pons S, Lorenzo D, Bernis C, Arrizabalaga P,

Fernández-Juárez G, Barrio V, Sierra M, Castellanos I, Espinosa M, Rivera F,

Oliet A, Fernández-Vega F, Praga M. Spontaneous Remission of Nephrotic

Syndrome in Idiopathic Membranous Nephropathy. J Am Soc Nephrol. 2010; 21:

699-704.

[12] Vogt L, Navis G, Köster J, Manolis AJ, Reid JL, de Zeeuw D. The angiotensin II

receptor antagonist telmisartan reduces urinary albumin excretion in patients with

isolated systolic hypertension: results of a randomized, double-blind, placebo-

controlled trial. J Hypertens. 2005; 23: 2055-2061.

18 Table 1 Patient profile at the start of hydrochrolothiazide administration

Case Age /sex Duration of Histopathology Remission Frequency Maximum Minimum daily Use of RAS (year) the disease Ehrenreich-Churg Interstitial of relapse urine protein dose of the drug blockades (mo) Classification lesion at relapse for remission (g/d) (mg/d) １ 68/male 96 III ++ CR 4 10.2 CsA 175 Candesartan

2 70/male 60 II + PR 4 5.8 CsA 100 Candesartan

3 60/female 136 ND + PR 5 4.1 PSL 15 Telmisartan

4 68/female 160 I + CR 8 19.9 PSL 15 Candesartan with CsA 75

5 64/female 161 I _ PR 5 4.0 PSL 5 Losartan

6 58/male 64 II + CR 4 7.6 PSL 10 Losartan

ND: not done, CR: complete remission, PR: partial remission, CsA: cyclosporine A, PSL: prednisolone. The grade of interstitial lesions is indicated as −, negative; +, mild; ++, moderate; +++, severe.

19 Table 2 Changes in clinical findings by addition of hydrochrolothiazide in six cases

HCT ( - ) HCT (＋)

Case BP Cre Urine protein FENa BP Cre Urine protein FENa HCT Latest dose of PSL-CsA (mmHg) (mg/dl) at remission (mmHg) (mg/dl) at remission (mg/d) (mg/d)/ (% of base line) (g/d) (g/d) 1 138/70 1.93 < 0.1 2.24 130/68 1.82 < 0.1 2.39 25 CsA 25/ (14)

2 120/72 0.87 1.0 1.65 132/78 0.84 < 0.1 2.90 25 Withdrawal/ (0)

3 134/62 0.98 0.22 0.75 130/68 1.08 0.25 1.59 25 PSL 3/ (20)

4 130/78 0.73 < 0.1 0.87 120/70 0.85 < 0.1 1.00 12.5 PSL 3/ (20) with CsA 25/ (33)

5 112/72 0.48 0.36 0.56 110/62 0.53 < 0.1 0.88 12.5 Withdrawal/ (0)

6 126/80 1.02 < 0.1 0.72 120/72 1.04 < 0.1 1.02 12.5 PSL 3/ (33)

HCT: hydrochrothiazide, Cre: serum creatinine, FENa: fractional excretion of sodium, PSL: prednisolone, CsA: cyclosporine A,